PNHP

‘Sicko’ economics, round 2

‘Sicko’ economics, round 2

David Felix, economist
Bangor Daily News
Wednesday, August 1, 2007

John Goodman summarizes his critique of Michael Moore’s documentary on health care reform (“Sicko is no model for health care reform,” BDN, July 21), as follows: “So what are we to make of Moore and his ‘documentary’? Economists, like other scientists, study reality in order to adapt to it. Artists, by contrast, selectively focus on some facts and ignore others in order to recreate reality.” Bad economics is thus Goodman’s basic charge against “Sicko.”

This charge prompted me, an economist, to see the documentary. My conclusion? Moore is far less guilty of flawed economics and disregard of relevant facts than is Goodman. Moore is also straightforward about his values and ideology, whereas Goodman masks his as scientific economics. This impels me to defend my profession by exposing the falsity of his claims, and some of the salient facts that he ignores.

Goodman rejects single payer universal coverage health systems, which Moore favors, because they require bureaucratic rationing of medical care, and impose longer waiting periods than do private market health systems. The rationing complaint as such is irrelevant; markets also ration, mostly by the purse. What they have been unable to do is provide universal coverage.

The incentive for private health insurance companies is to maximize profits by insuring low-risk clients and rejecting high risk ones. That incentive promotes /private /bureaucratic rationing of services and intensified screening of applicants. The U.S. public sector and private charities have thus been pressured to finance treatment of some sort for the rapidly rising millions of U.S. uninsured and underinsured. “Sicko” illustrates various aspects of the problem. Goodman gives it no mention whatsoever.

Waiting time is emphasized by Goodman, although he ignores some important dimensions of the waiting issue, and presents biased treatment of others.

Thus the socialized systems of Britain, Canada, Australia and New Zealand assign lower priorities and longer delays to elective (e.g., cosmetic) and non-emergency (e.g., hip replacement) surgery than to emergency (e.g., cardiac or cancer) surgery.

The U.S. has the shortest average waiting time for elective and non-emergency surgery, but is merely in the middle of the Anglo-Saxon group for emergency surgery. The same for delay in seeing a specialist.

Goodman combines the two priorities, lowering the overall U.S. waiting time to first place, which allows him to claim it indicates the extra risk of death that government rationing imposes in emergency cases.

He disregards that the U.S. is the most difficult of the Anglo-Saxon group in getting same-day doctor appointments; shares with Canada the most difficulty in getting treatment on nights and weekends; and that France, Germany, Japan and the Scandinavians have still shorter delays than the Anglo-Saxon group in almost all dimensions of waiting. Implication? Bureaucratic rationing is unavoidable in universal coverage government health programs, but longer waits are not.

Goodman’s data manipulation and his assumption that longer waits have deadly consequences imply that the U.S. should have longer life expectancy and a lower rate of infant mortality than the industrial countries with socialized medicine.

But he doesn’t test that implication, enabling him to ignore that the U.S. has the lowest life expectancy and highest infant mortality rate of the industrialized democracies. Instead, he puzzles over why national health insurance seems so popular in these countries, concluding it’s because their citizenry, unaware that they pay by taxes, think they’re getting something for nothing.

And so to another of Goodman’s major omissions. The overall cost of health, taxes and all, is far higher in the U.S. than in any of the countries with universal coverage socialized health systems. U.S. overall spending on health is pushing 16 percent of its GDP and rising, as are its millions of uninsured. The overall health spending of the countries with socialized health insurance averages around 10 percent of GDP, with none reaching 12 percent, and all providing universal coverage. We pay the most to cover the least.

Can we cover more while paying less? Kenneth Thorpe, perhaps the top U.S. health economist, was recently commissioned by a broad coalition of 90 corporations, unions and advocacy groups to answer the question statistically. His report estimates the annual cost of moving to universal coverage at $75 billion in constant U.S. dollars, but this could be more than offset by reducing administrative costs to the Canadian level, acquiring pharmaceuticals at Canadian prices, and by earlier detection and treatment of patients now priced out of the current health system.

The annual savings in 10 years would reach $125 billion, with the current health system preserved, up to $182 billion if transformed to a single payer insurance system. These numbers estimate what economists call deadweight losses, inefficient uses of resources that reduce national welfare. “Sicko” illustrates such losses in the U.S. system; Goodman ignores them.

Which brings us to the moral issue. The major religions advocate egalitarian distribution of social welfare theologically, whereas libertarian ideology prioritizes free markets and individual choice. Each can become enmeshed by policy conflicts between theology and economic reality.

Health reform is an exception. Moore has the easier advocacy task: his single-payer reform is supported by both “scientific” economics and widely held religious principles.

Goodman must show that socializing health insurance, even if it lowers economic costs while improving health, is morally bad. His critique avoids that question, other than hinting at a slippery slope argument. My conclusion: Moore wins over Goodman on economics and morality.

David Felix of Orono is professor emeritus of economics at Washington University in St. Louis.

Canadian Medical Association's proposal for Medicare Plus

Medicare Plus

Canadian Medical Association
CMA Policy Statement
July 2007

To sustain Canada’s health care system for the next generation, changes need to be made to bring about a new vision for Medicare. The CMA identifies this future vision as “Medicare Plus.”

The Chaoulli decision has established that patients cannot be denied a private sector insurance and treatment option. The Quebec government has since made provisions in its legislation to comply with the decision, however it has so narrowly circumscribed the terms and conditions under which private insurance contracts might be offered and delivered that it is highly unlikely private coverage will be offered.

The ability of physicians to choose whether or not to participate in the public health insurance plan has been a key feature of Medicare since its inception. Physicians are willing to accept reasonable limits on their ability to opt in or out of the public health plan to ensure that adequate access to medical services is maintained. To achieve this, an effective regulatory framework is required to govern the intersection of public and private health care and there must be concerted effort on the part of stakeholders to investigate the implications of and opportunities to minimize conflicts of interest. When considering options for the delivery of publicly insured services by the private sector, it is critical that the integrity of the public system is maintained and that Medicare remain the cornerstone of Canadian health care.

The CMA recommends that:

When access to timely care cannot be provided in the publicly funded system, Canadians should be able to use private health insurance to reimburse the cost of care obtained in the private sector.

http://www.cma.ca//multimedia/CMA/Content_Images/Inside_cma/Advocacy/MedicarePlus/still_about_access.pdf

And…

The case against private insurance

By Naomi Lakritz
Calgary Herald
August 2, 2007

It’s been said that during the 12 or so years they spend in medical school, doctors learn to think of themselves as gods.

Well, the gods must be crazy. Or greedy. Or both. How else to explain the Canadian Medical Association’s ridiculous support for physicians’ right to work simultaneously in both a public and private system, including the introduction of private health insurance — and the gall to label this as standing up for their patients?

It is patently obvious they are standing up for their bank accounts, not their patients. That they are so eager to place patients at the mercy of insurance companies, whose subterfuges for skipping out on claims are well-documented in the U.S., shows their patients’ best interests are the last priority.

A recent New York Times article profiled Gordon Hendrickson, 66, of Albuquerque, whose best bet to beat pancreatic cancer was risky surgery performed by a Houston specialist. His insurance company refused to pay for the surgery. Hendrickson had it done anyway. Today, he is cured, but owes $80,000 in medical bills.

Is this what the CMA wants to inflict on Canadians?

“Of the people who go bankrupt in the U.S., 50 per cent of the time it is because of medical bills. Of that 50 per cent, 75 per cent had health insurance,” says Dr. Ida Hellander, executive director of the Chicago-based Physicians For a National Health Program.

Insurance companies are putting the screws to American patients in insidious ways.

In a telephone interview, Hellander says it’s hard to find a policy with a deductible less than $1,000. Some policies have deductibles up to $5,000.

“A thousand dollars is a lot of money. So people have chest pains and they won’t go to the ER because they’ll have to pay that $1,000 deductible,” she says.

Another nasty trend is co-insurance — when you go to the hospital, you pay 20 per cent of the bill before your insurance kicks in.

Insurers have also dropped mental health coverage, so people with mental illnesses are going untreated. Only the most indigent can get their mental health care funded by the government. Also, if you have a pre-existing condition, insurance companies will do their best to link it to everything else you visit the doctor for, in order to avoid paying the bill.

And the CMA wants to subject Canadians to these kinds of nightmares?

Equally absurd is the CMA’s claim that these reforms would allow doctors to spend more time with patients. Sure, they would — with the private patients whose visits are more lucrative for the doctor.

The public patients might be fitted in if there are a few minutes left over in the doctor’s day from filling out the insurance forms for his private patients.

According to an article in the Ventura County Star, 80 per cent of doctors in California are frustrated with the huge amount of time they spend filling out insurance forms.

Don McCanne, a retired family physician and senior health policy fellow with the PNHP, says doctors will be “cream-skimming the more profitable patients,” to the detriment of the public ones.

Economist Paul Krugman, also writing in the New York Times, shatters one of the cherished myths of Canada’s proponents of private health, when he discusses hip replacements. This surgery is always seized upon by the private-health cheerleaders as something for which there is no waiting in the U.S. system:

“There’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

“That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare because it has more lavish funding.”

Krugman also points out that the insurers themselves cause waiting lists to grow, citing the example of Mark Kleiman, a UCLA professor, who nearly died waiting for a biopsy because his insurance company stalled approving it.

“There’s no question that some Americans who seemingly have good insurance nonetheless die because insurers are trying to hold down their ‘medical losses’ — the industry term for actually having to pay for care,” Krugman writes.

Reached at his home in San Juan Capistrano, Calif., McCanne calls the CMA’s interest in private care “self-serving” at a time when Canada really needs to repair the public system’s flaws.

“Frankly, they’re greedy,” he says. “Private insurance is the worst thing they could do.”

Amen to that, Dr. McCanne.

http://www.canada.com/calgaryherald/news/theeditorialpage/story.html?id=ab96889d-3cbc-4d5d-87ce-ad46de9db0a3

And the latest…

CBC News

Health Minister Tony Clement has rebuffed the Canadian Medical Association in its call for greater privatization of medicare.

Clement said the federal government will not allow so-called dual practice, which allows doctors to work in both the public and private health systems. In an interview, he referred to such an arrangement as a two-tier system.

Clement said the doctors’ organization is entitled to its opinion but the government believes the CMA proposal would breach the Canada Health Act.

The minister was responding to a letter from the Registered Nurses Association of Ontario, which called on Prime Minister Stephen Harper to uphold the single-tier system.

http://www.cbc.ca/cp/health/070801/x080121A.html

Reason to rejoice…

It is important to understand that the greed brush does not paint all physicians. Just as dedicated physicians in the United States formed Physicians for a National Health Program (PNHP) in response to the flawed reform proposals of the American Medical Association, dedicated physicians in Canada have formed Canadian Doctors for Medicare (CDM).

Their Mission:

“The mission of CDM is to provide a voice for Canadian doctors who believe in and support Canada’s publicly funded system for physician and hospital care, and who reject private insurance and direct payment for these medically necessary services.”

http://www.canadiandoctorsformedicare.ca/mainpage.html

Comment:

By Don McCanne, MD

Amen.

The case against private insurance

Naomi Lakritz
Calgary Herald
Thursday, August 02, 2007

It’s been said that during the 12 or so years they spend in medical school, doctors learn to think of themselves as gods.

Well, the gods must be crazy. Or greedy. Or both. How else to explain the Canadian Medical Association’s ridiculous support for physicians’ right to work simultaneously in both a public and private system, including the introduction of private health insurance — and the gall to label this as standing up for their patients?

It is patently obvious they are standing up for their bank accounts, not their patients. That they are so eager to place patients at the mercy of insurance companies, whose subterfuges for skipping out on claims are well-documented in the U.S., shows their patients’ best interests are the last priority.

A recent New York Times article profiled Gordon Hendrickson, 66, of Albuquerque, whose best bet to beat pancreatic cancer was risky surgery performed by a Houston specialist. His insurance company refused to pay for the surgery. Hendrickson had it done anyway. Today, he is cured, but owes $80,000 in medical bills.

Is this what the CMA wants to inflict on Canadians?

“Of the people who go bankrupt in the U.S., 50 per cent of the time it is because of medical bills. Of that 50 per cent, 75 per cent had health insurance,” says Dr. Ida Hellander, executive director of the Chicago-based Physicians For a National Health Program.

Insurance companies are putting the screws to American patients in insidious ways.

In a telephone interview, Hellander says it’s hard to find a policy with a deductible less than $1,000. Some policies have deductibles up to $5,000.

“A thousand dollars is a lot of money. So people have chest pains and they won’t go to the ER because they’ll have to pay that $1,000 deductible,” she says.

Another nasty trend is co-insurance — when you go to the hospital, you pay 20 per cent of the bill before your insurance kicks in.

Insurers have also dropped mental health coverage, so people with mental illnesses are going untreated. Only the most indigent can get their mental health care funded by the government. Also, if you have a pre-existing condition, insurance companies will do their best to link it to everything else you visit the doctor for, in order to avoid paying the bill.

And the CMA wants to subject Canadians to these kinds of nightmares?

Equally absurd is the CMA’s claim that these reforms would allow doctors to spend more time with patients. Sure, they would — with the private patients whose visits are more lucrative for the doctor.

The public patients might be fitted in if there are a few minutes left over in the doctor’s day from filling out the insurance forms for his private patients.

According to an article in the Ventura County Star, 80 per cent of doctors in California are frustrated with the huge amount of time they spend filling out insurance forms.

Don McCanne, a retired family physician and senior health policy fellow with the PNHP, says doctors will be “cream-skimming the more profitable patients,” to the detriment of the public ones.

Economist Paul Krugman, also writing in the New York Times, shatters one of the cherished myths of Canada’s proponents of private health, when he discusses hip replacements. This surgery is always seized upon by the private-health cheerleaders as something for which there is no waiting in the U.S. system:

“There’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

“That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare because it has more lavish funding.”

Krugman also points out that the insurers themselves cause waiting lists to grow, citing the example of Mark Kleiman, a UCLA professor, who nearly died waiting for a biopsy because his insurance company stalled approving it.

“There’s no question that some Americans who seemingly have good insurance nonetheless die because insurers are trying to hold down their ‘medical losses’ — the industry term for actually having to pay for care,” Krugman writes.

Reached at his home in San Juan Capistrano, Calif., McCanne calls the CMA’s interest in private care “self-serving” at a time when Canada really needs to repair the public system’s flaws.

“Frankly, they’re greedy,” he says. “Private insurance is the worst thing they could do.”

Amen to that, Dr. McCanne.

nlakritz@theherald.canwest.com

Canadian Medical Association’s proposal for Medicare Plus

Medicare Plus

Canadian Medical Association
CMA Policy Statement
July 2007

To sustain Canada’s health care system for the next generation, changes need to be made to bring about a new vision for Medicare. The CMA identifies this future vision as “Medicare Plus.”

The Chaoulli decision has established that patients cannot be denied a private sector insurance and treatment option. The Quebec government has since made provisions in its legislation to comply with the decision, however it has so narrowly circumscribed the terms and conditions under which private insurance contracts might be offered and delivered that it is highly unlikely private coverage will be offered.

The ability of physicians to choose whether or not to participate in the public health insurance plan has been a key feature of Medicare since its inception. Physicians are willing to accept reasonable limits on their ability to opt in or out of the public health plan to ensure that adequate access to medical services is maintained. To achieve this, an effective regulatory framework is required to govern the intersection of public and private health care and there must be concerted effort on the part of stakeholders to investigate the implications of and opportunities to minimize conflicts of interest. When considering options for the delivery of publicly insured services by the private sector, it is critical that the integrity of the public system is maintained and that Medicare remain the cornerstone of Canadian health care.

The CMA recommends that:

When access to timely care cannot be provided in the publicly funded system, Canadians should be able to use private health insurance to reimburse the cost of care obtained in the private sector.

http://www.cma.ca//multimedia/CMA/Content_Images/Inside_cma/Advocacy/MedicarePlus/still_about_access.pdf

And…

The case against private insurance

By Naomi Lakritz
Calgary Herald
August 2, 2007

It’s been said that during the 12 or so years they spend in medical school, doctors learn to think of themselves as gods.

Well, the gods must be crazy. Or greedy. Or both. How else to explain the Canadian Medical Association’s ridiculous support for physicians’ right to work simultaneously in both a public and private system, including the introduction of private health insurance — and the gall to label this as standing up for their patients?

It is patently obvious they are standing up for their bank accounts, not their patients. That they are so eager to place patients at the mercy of insurance companies, whose subterfuges for skipping out on claims are well-documented in the U.S., shows their patients’ best interests are the last priority.

A recent New York Times article profiled Gordon Hendrickson, 66, of Albuquerque, whose best bet to beat pancreatic cancer was risky surgery performed by a Houston specialist. His insurance company refused to pay for the surgery. Hendrickson had it done anyway. Today, he is cured, but owes $80,000 in medical bills.

Is this what the CMA wants to inflict on Canadians?

“Of the people who go bankrupt in the U.S., 50 per cent of the time it is because of medical bills. Of that 50 per cent, 75 per cent had health insurance,” says Dr. Ida Hellander, executive director of the Chicago-based Physicians For a National Health Program.

Insurance companies are putting the screws to American patients in insidious ways.

In a telephone interview, Hellander says it’s hard to find a policy with a deductible less than $1,000. Some policies have deductibles up to $5,000.

“A thousand dollars is a lot of money. So people have chest pains and they won’t go to the ER because they’ll have to pay that $1,000 deductible,” she says.

Another nasty trend is co-insurance — when you go to the hospital, you pay 20 per cent of the bill before your insurance kicks in.

Insurers have also dropped mental health coverage, so people with mental illnesses are going untreated. Only the most indigent can get their mental health care funded by the government. Also, if you have a pre-existing condition, insurance companies will do their best to link it to everything else you visit the doctor for, in order to avoid paying the bill.

And the CMA wants to subject Canadians to these kinds of nightmares?

Equally absurd is the CMA’s claim that these reforms would allow doctors to spend more time with patients. Sure, they would — with the private patients whose visits are more lucrative for the doctor.

The public patients might be fitted in if there are a few minutes left over in the doctor’s day from filling out the insurance forms for his private patients.

According to an article in the Ventura County Star, 80 per cent of doctors in California are frustrated with the huge amount of time they spend filling out insurance forms.

Don McCanne, a retired family physician and senior health policy fellow with the PNHP, says doctors will be “cream-skimming the more profitable patients,” to the detriment of the public ones.

Economist Paul Krugman, also writing in the New York Times, shatters one of the cherished myths of Canada’s proponents of private health, when he discusses hip replacements. This surgery is always seized upon by the private-health cheerleaders as something for which there is no waiting in the U.S. system:

“There’s a funny thing about that example, which is used constantly as an argument for the superiority of private health insurance over a government-run system: the large majority of hip replacements in the United States are paid for by, um, Medicare.

“That’s right: the hip-replacement gap is actually a comparison of two government health insurance systems. American Medicare has shorter waits than Canadian Medicare because it has more lavish funding.”

Krugman also points out that the insurers themselves cause waiting lists to grow, citing the example of Mark Kleiman, a UCLA professor, who nearly died waiting for a biopsy because his insurance company stalled approving it.

“There’s no question that some Americans who seemingly have good insurance nonetheless die because insurers are trying to hold down their ‘medical losses’ — the industry term for actually having to pay for care,” Krugman writes.

Reached at his home in San Juan Capistrano, Calif., McCanne calls the CMA’s interest in private care “self-serving” at a time when Canada really needs to repair the public system’s flaws.

“Frankly, they’re greedy,” he says. “Private insurance is the worst thing they could do.”

Amen to that, Dr. McCanne.

http://www.canada.com/calgaryherald/news/theeditorialpage/story.html?id=ab96889d-3cbc-4d5d-87ce-ad46de9db0a3

And the latest…

CBC News

Health Minister Tony Clement has rebuffed the Canadian Medical Association in its call for greater privatization of medicare.

Clement said the federal government will not allow so-called dual practice, which allows doctors to work in both the public and private health systems. In an interview, he referred to such an arrangement as a two-tier system.

Clement said the doctors’ organization is entitled to its opinion but the government believes the CMA proposal would breach the Canada Health Act.

The minister was responding to a letter from the Registered Nurses Association of Ontario, which called on Prime Minister Stephen Harper to uphold the single-tier system.

http://www.cbc.ca/cp/health/070801/x080121A.html

Reason to rejoice…

It is important to understand that the greed brush does not paint all physicians. Just as dedicated physicians in the United States formed Physicians for a National Health Program (PNHP) in response to the flawed reform proposals of the American Medical Association, dedicated physicians in Canada have formed Canadian Doctors for Medicare (CDM).

Their Mission:

“The mission of CDM is to provide a voice for Canadian doctors who believe in and support Canada’s publicly funded system for physician and hospital care, and who reject private insurance and direct payment for these medically necessary services.”

http://www.canadiandoctorsformedicare.ca/mainpage.html

Comment:

By Don McCanne, MD

Amen.

Rudy Giuliani's health care proposal

Rudy Giuliani Campaign Announces Health Care Advisors

RUDY
www.JoinRudy2008.com
July 30, 2007

The Rudy Giuliani Presidential Committee today announced key advisors who have been providing input on Rudy Giuliani’s commitment to providing affordable free-market-based solutions to health care aimed at giving Americans more control over and access to their health care.

The Mayor’s group of advisors includes well-known advocates of consumer-driven health care and recognized leaders in their respective areas of expertise.

“Rudy Giuliani strongly believes in limited government and giving American families more control over their health care decisions,” said Steve Goldsmith, the campaign’s Chief Domestic Policy Advisor. “He understands that failed mandates and wasteful, unaccountable bureaucracies lead to the exclusion of millions of Americans from quality care and health insurance.”

The Advisors:

Dan Kessler, Ph.D. – a senior fellow at the Hoover Institution and a professor at the Graduate School of Business at Stanford University, and co-author of Healthy, Wealthy, and Wise (advocates a free market solution to reform).

Scott Atlas, M.D. – a senior fellow by courtesy at the Hoover Institution whose research includes free market solutions to health care.

David Gratzer, M.D. – a senior fellow at the Manhattan Institute whose most recent book, with Foreword by Milton Friedman, is The Cure: How Capitalism Can Save American Health Care.

Sally C. Pipes – president and chief executive officer of the Pacific Research Institute, a San Francisco-based think tank. Previously she was assistant director of the Fraser Institute.

Donald W. Moran – served as the Executive Associate Director for Budget and Legislation at the U.S. Office of Management & Budget under President Ronald Reagan.

http://www.joinrudy2008.com/news/pr/548

And…

Giuliani attacks Democratic health plans as ‘socialist’

By Paul Steinhauser
CNN.com/politics
July 31, 2007

Republican presidential candidate Rudy Giuliani said Tuesday he wants to give American citizens more control over their health care.

“We’ve got to do it the American way,” Giuliani said during a town hall forum in Rochester, New Hampshire. “The American way is not single-payer, government-controlled anything.”

“That’s why when you hear Democrats in particular talk about single-mandated health care, universal health care, what they’re talking about is socialized medicine.”

Giuliani’s health care plan, unveiled at the forum, includes giving taxpayers tax credits to purchase private health insurance. The highlight of Giuliani’s plan: a $15,000 tax deduction for each family to buy private health insurance.

He says his program for private insurance would replace coverage from employers.

While outlining his plan, Giuliani offered few details.

http://www.cnn.com/2007/POLITICS/07/31/giuliani.democrats/

Comment:

By Don McCanne, MD

Rudy Giuliani’s choice of health care advisors is all you need to know to understand his positions on reform. His decision to trump rational health policy with extremist libertarian ideology does tend to make you question his political skills. He obviously isn’t poll driven.

Canada fights privatization

Self-interest over public interest

By Prof. Gordon Guyatt
The Globe and Mail
01/08/07

Any proposed change to health care implies winners and losers.

Take, for instance, a national Pharmacare program. Winners would include poor Canadians who have difficulty affording drugs, middle income Canadians with high drug costs, and anyone facing catastrophic drug expenditures.
Canadian large industry would also benefit by enhanced competitiveness as a result of lower employee health benefits.

The losers? High income Canadians in upper tax brackets and the insurance industry.

The Canadian Medical Association has recently suggested that provincial governments increase reliance on private, for-profit providers to deliver publicly funded health care. Furthermore, they suggest that physicians be allowed to practice in both for-profit and not-for-profit sectors. Who would win and lose if governments accept the proposal?
The CMA claims that the public would benefit from shorter waiting lists. There are many reasons for skepticism about the claim.

Long wait times and suboptimal care are in considerable part a function of doctor and nursing shortages. For-profit clinics would not lead to the training of a single additional doctor or nurse. Indeed, such clinics would suck desperately needed personnel from not-for-profit hospitals and outpatient facilities.

Physicians practicing in public and private settings they have a vested interest in keeping waiting lists long in publicly funded settings. Why would patients pay extra if waiting lists are under control in publicly funded hospitals and out-patient clinics? They would not. For-profit clinics prosper only so long as non-profit provision suffers unacceptable waits.

Could for-profit clinics shorten waiting lists by creating more resources, such as operating room time? Surely, but the government could create those same resources by investment in hospitals or not-for-profit dedicated surgical and diagnostic facilities.

Investing in not-for-profit provision has a major advantage. For-profit providers need to earn a return — typically 15 to 20% – for their investors. Non-profits can devote that money to patient care. That explains the findings from systematic studies comparing for-profit versus non-profit hospital and dialysis care in the U.S. Higher death rates from cutting corners in for-profit hospitals and dialysis facilities, higher charges to third-party payers in for-profit hospitals.

So, too bad, no public win in terms of wait time reduction.

There would, however, be winners. Physician entrepreneurs like incoming CMA President Brian Day who operates a private hospital facility stand to make large sums of money. Many investors have made huge sums of money in U.S. for-profit health care. The proposal would allow them to exploit the enormous public expenditures on Canadian health care. And, if an associated CMA proposal to expand private insurance comes to pass, the insurance industry will cash in.

The losers? The general public who will end up spending more on health care to feed the investors’ profits and — if that market expands – on administrative costs associated with private health insurance. Those patients who can’t afford the substantial direct charges that — as experience in British Columbia and Quebec has shown — will inevitably come with for-profit health care provision. These losers will suffer the consequences of two-tier health care: the long waits in non-profit facilities necessary to allow the for-profits to charge queue-jumpers.

Other losers? Health workers who believe that ethical medical practice requires treating patients according to need, rather than ability to pay. My many visits to American health care institutions have shown me what it is like to practice medicine in a two-tier system. For doctors and nurses who believe that equity is at the heart of ethical care, it isn’t pleasant.

Consideration of winners and loser reveals a sad conclusion. While many doctors are in strong disagreement with proposals that would undermine public health care, the CMA leadership has chosen self-interest over the public interest.

How will politicians respond to the CMA initiative? Stephen Harper has done nothing to rein in expansions of charge-the-patient for-profit care in Quebec and B.C. On the other hand, the Prime Minister sees the situation as it is. In a letter responding to Ralph Klein’s proposal to allow physicians to practice in public and private systems, Mr. Harper wrote:

“Dual practice creates conflict of interest for physicians as there would be a financial incentive for them to stream patients into the private portion of their practice. Furthermore, dual practice legitimizes queue-jumping as it provides an approved mechanism for patients to pay to seek treatment at the front of the line.”

Whether for political expediency or conviction, the federal government may have nothing to do with the CMA’s proposals. If so, the losers will be the doctors and investors eager to turn health care to profit, and the winners will be the Canadian public.

Gordon Guyatt is a Professor of Medicine at McMaster University

New fight looms over medicare

Toronto Star
EDITORIAL
Aug 01, 2007

Once again the Canadian Medical Association, the national lobby group for Canada’s doctors, has started beating the drums for two-tier health care. In a speech Monday in Charlottetown, outgoing CMA president Collin McMillan set out a plan he calls “Medicare Plus.”

It is a blueprint that would see Canadians being allowed more access to private health insurance that could be used in a private system and which operates alongside medicare’s publicly funded coverage for all Canadians. Also under the plan, as set out in a policy paper released by the CMA, doctors would be free to divide their time as they see fit between public practice and a private one for those Canadians with cash or private insurance.

This is nothing short of a recipe for two-tier medicine.

But it rests on two flawed assumptions: first, that medicare is broken, and second, that it is too expensive for governments to fix.

As former Saskatchewan premier Roy Romanow concluded in 2002 after his exhaustive, 18-month review of Canada’s publicly funded, not-for-profit health-care system, medicare is far from broken. And all the well-known problems with the current system that arose at a time when Ottawa was preoccupied with fighting its deficit can be fixed at a reasonable cost.

In fact, since Romanow reported five years ago, important progress has been made on many fronts, although there is still much to be done.

Both Ottawa and provincial governments have invested heavily in health care, which has resulted in shorter wait times in many key areas, an increase in the availability of sophisticated diagnostic equipment and the introduction of programs of enhanced primary care. These advances, however, have not stopped the champions of private health care from continuing to push for two-tier medicine in Canada.

Indeed, Canada is heading rapidly toward yet another major national fight over the future of medicare.

Defenders of medicare have fought these battles in the past – and will need to speak up again in the coming fight. And they cannot afford to underestimate their opponents.

If anything, McMillan’s speech on Monday is merely the opening salvo in this debate. The next major battleground will be the provincial election in Ontario.

Here, Progressive Conservative Party Leader John Tory’s election platform promises “to involve the private sector where there are opportunities to shorten waiting lists and improve access to high-quality, publicly funded care.” Many in his party want to see widespread use of privately run, but publicly funded clinics. Although such proponents insist that patients would not be allowed to buy their way to the front of the line, their arguments in favour of private delivery have been used repeatedly like a crowbar by those trying to pry open the door to two-tier medicine.

At the national level, the pressure on Ottawa and the provinces to experiment more with private health care will start to increase next month when Brian Day takes over from McMillan at the CMA. A vociferous critic of the public system, Day is also the owner of Canada’s largest private hospital, based in Vancouver.

On the other side of the divide are the vast majority of Canadians, who overwhelmingly support medicare. They will have a critical part to play as this renewed debate unfolds.

To counter those who favour increased privatization, these Canadians must re-energize themselves and prepare once again to take on the claims of affordability and increased efficiency that proponents of private care use to sell their case.

Most importantly, they must continue to press governments to improve the current system and be ready with their own prescriptions for completing the work that still needs to be done to restore the public’s confidence in a system that has served Canada well.

For as Romanow wrote in the introduction to his 2002 report: “Strong leadership and the involvement of Canadians is key to preserving a system that is true to our values and sustainable.”

Rudy Giuliani’s health care proposal

Rudy Giuliani Campaign Announces Health Care Advisors

RUDY
www.JoinRudy2008.com
July 30, 2007

The Rudy Giuliani Presidential Committee today announced key advisors who have been providing input on Rudy Giuliani’s commitment to providing affordable free-market-based solutions to health care aimed at giving Americans more control over and access to their health care.

The Mayor’s group of advisors includes well-known advocates of consumer-driven health care and recognized leaders in their respective areas of expertise.

“Rudy Giuliani strongly believes in limited government and giving American families more control over their health care decisions,” said Steve Goldsmith, the campaign’s Chief Domestic Policy Advisor. “He understands that failed mandates and wasteful, unaccountable bureaucracies lead to the exclusion of millions of Americans from quality care and health insurance.”

The Advisors:

Dan Kessler, Ph.D. – a senior fellow at the Hoover Institution and a professor at the Graduate School of Business at Stanford University, and co-author of Healthy, Wealthy, and Wise (advocates a free market solution to reform).

Scott Atlas, M.D. – a senior fellow by courtesy at the Hoover Institution whose research includes free market solutions to health care.

David Gratzer, M.D. – a senior fellow at the Manhattan Institute whose most recent book, with Foreword by Milton Friedman, is The Cure: How Capitalism Can Save American Health Care.

Sally C. Pipes – president and chief executive officer of the Pacific Research Institute, a San Francisco-based think tank. Previously she was assistant director of the Fraser Institute.

Donald W. Moran – served as the Executive Associate Director for Budget and Legislation at the U.S. Office of Management & Budget under President Ronald Reagan.

http://www.joinrudy2008.com/news/pr/548

And…

Giuliani attacks Democratic health plans as ‘socialist’

By Paul Steinhauser
CNN.com/politics
July 31, 2007

Republican presidential candidate Rudy Giuliani said Tuesday he wants to give American citizens more control over their health care.

“We’ve got to do it the American way,” Giuliani said during a town hall forum in Rochester, New Hampshire. “The American way is not single-payer, government-controlled anything.”

“That’s why when you hear Democrats in particular talk about single-mandated health care, universal health care, what they’re talking about is socialized medicine.”

Giuliani’s health care plan, unveiled at the forum, includes giving taxpayers tax credits to purchase private health insurance. The highlight of Giuliani’s plan: a $15,000 tax deduction for each family to buy private health insurance.

He says his program for private insurance would replace coverage from employers.

While outlining his plan, Giuliani offered few details.

http://www.cnn.com/2007/POLITICS/07/31/giuliani.democrats/

Comment:

By Don McCanne, MD

Rudy Giuliani’s choice of health care advisors is all you need to know to understand his positions on reform. His decision to trump rational health policy with extremist libertarian ideology does tend to make you question his political skills. He obviously isn’t poll driven.

Presbyterian Health fought Whipple at M. D. Anderson

Doing Battle With the Insurance Company in a Fight to Stay Alive

By Denise Grady
The New York Times
July 29, 2007

A glorious blend of forces came together to save Gordon Hendrickson’s life: smart doctoring, luck, kindness, and his own wisdom and abundant grit.

Only his insurance company tried to stand in the way.

His doctors thought he was among the lucky few with pancreatic cancer found early enough to be cured by surgery. But they warned him not to have the surgery in his home city, Albuquerque. They said the operation he needed, a Whipple procedure, was so risky and complicated that it should be done only by a surgeon who performed it often and at a hospital with many similar cases. But neither was available locally.

…his internist, Dr. Kristine Bordenave… canceled her other appointments to spend hours on the phone finding a major cancer center that would quickly admit him. It turned out to be the M. D. Anderson Cancer Center in Houston.

But his insurer, the Presbyterian Health Plan, refused to pay for treatment in Houston. The company insisted that the operation be done in Albuquerque and sent him a list of five local surgeons.

He went to M. D. Anderson anyway.

Mr. Hendrickson had the surgery. It went well. But he was left with more than $80,000 in medical bills, which Presbyterian Health Plan refused to pay.

Mr. Hendrickson waged a long battle with Presbyterian.

After Presbyterian rejected two appeals, he took his case to a state review board, where he represented himself because he could not afford a lawyer.

Ultimately, Mr. Hendrickson won the case, and Presbyterian Health Plan paid the entire bill.

http://www.nytimes.com/2007/07/29/health/29OBSTACLES.html?adxnnl=1&adxnnlx=1185712600-tpCl49Yqw7WlMUs6wqw8Gg

About Presbyterian Healthcare Services:
http://www.phs.org/admin/about_us.shtml

Comment:

By Don McCanne, MD

The appropriate medical decision could not be more straightforward. A Whipple procedure should always be done in a center with an experienced team. To attempt this operation at a local level with an inexperienced team is almost tantamount to a death sentence.

Had Mr. Hendrickson been covered by the traditional Medicare program, the referral would have been made promptly to M. D. Anderson Cancer Center without the need to consider any other referral options, the operation would have been completed, and Medicare would have paid the bills. End of story.

But no. His coverage was through Presbyterian Health Plan, an intrusive third party payer that held contracts with the patient on the consumer side, and with a specific list of physicians and hospitals on the provider side. The contracts allowed Presbyterian Health Plan to use a basic business decision to overrule a crucial medical decision. This clearly caused Mr. Hendrickson considerable distress, and could have cost him his life.

One irony is that Presbyterian Health Plan is part of Presbyterian Healthcare Services which is a private, nonprofit statewide healthcare system with several hospitals, plus primary and specialty care through Presbyterian Medical Group. Single payer model proposals usually include coverage for integrated healthcare delivery systems, as long as their mission is providing health care rather than providing insurance services.

Suppose we adopted a single national health insurance program covering everyone for all reasonable beneficial services. Presbyterian Health Plan would be superfluous and could be eliminated. Payment for services could be made directly by the public insurance program. The patient could be free to continue to use Presbyterian Healthcare Services, but could also be free to use any other healthcare providers such as M. D. Anderson Cancer Center. Neither the patient nor the providers necessarily would be locked in by a contract.

But what if the integrated healthcare delivery system elected to be funded through capitation, as some single payer models would permit? That returns some of the financial risk to the delivery system, and locks the patient back in (otherwise the government would be paying, for the same patient, both a capitation fee for comprehensive services and fee-for-service costs outside of the system). The single payer model does call for funding hospitals through global budgets, so the hospital component of the integrated delivery system could be funded by global budgets as well. The medical group component could then be funded either by fee-for-service, or also by a global budget negotiated to cover legitimate costs plus fair compensation. Paying physicians by salary reduces the incentives to either withhold beneficial care or provide excessive services (although it risks sloth).

At any rate, Mr. Hendrickson’s experience provides us with yet one more example of why we need to remove private insurers from our financing of health care. Health care needs to be based strictly on medical need rather than on business decisions made by private insurers.

PNHP Debates Incoming AMA President

Is single-payer health care a good idea? A debate between Dr. Nancy Nielsen, president-elect of the American Medical Association and Dr.Don McCanne, Senior Policy Fellow for Physicians for a National Health Program. To hear the show, click HERE

Single payer debate with AMA President-Elect Nancy Nielsen

Is single-payer health care a good idea?

A debate between Dr. Nancy Nielsen, president-elect of the American Medical Association and Dr. Don McCanne, Senior Policy Fellow for Physicians for a National Health Program.
KALW, San Francisco
July 29, 2007

Hosted by Marty Nemko

Halfway through the debate:

Marty Nemko: You know, as I’m kind of stepping back and listening to this debate, at this moment in time in the debate, it’s seeming as though the advantages of lower costs that would accrue from reduced administrative costs that would come from single payer, the simplification of life that would come from single payer, and retention of choice in the single payer program that you’re advocating, that is choice of doctors and hospitals, right now makes it look like you’re winning. So I’d like to ask you, Don, some tough questions that I think will at least allow our listeners to hear the best answers to these kind of tough questions…

To hear the hour-long broadcast, click on “HERE” for the 7/29 archive:
http://www.martynemko.com/past-and-upcoming-radio-shows

Comment:

By Don McCanne, MD

Because of my obvious bias, I’ll not comment here on our respective opinions on the health care reform policies debated. The listeners can draw their own conclusions.

But I would like to mention one point of disagreement that could not be clarified during the limited time of the broadcast. I mentioned that the AMA’s version of choice was the choice of private health plans, allowing individuals to purchase plans with lower premiums, but at a cost of reducing the insurance function of the private plans. Those plans work for the healthy, but not for those who later develop significant medical problems. She replied that this does not at all represent the AMA’s proposal. She used the analogy that you would never buy an unsafe car, but rather you would choose a car with all of the safety features. But the 2007 AMA proposal for reform specifically states: “Benefit mandates should be minimized to allow markets to determine benefit packages and permit a wide choice of coverage options.” This point is absolutely crucial because it further demonstrates how poorly private plans would serve us in a universal system of health care coverage.

The best of the Blues

CMA Appalled by Blue Shield of California’s Failure to Settle RICO Lawsuit

California Medical Association
CMA Alert
July 26, 2007

CMA is outraged that Blue Shield of California has refused to settle a class-action lawsuit filed in 2003 that would have meant tens of millions of dollars to California physicians who were harmed by the insurer’s previous failures to provide and pay for patient care.

Despite the association’s best efforts to work amicably with this nonprofit insurance company — a company CMA founded — Blue Shield is demonstrating a disappointing unwillingness to provide its enrollees with the care for which they’ve paid.

Though not a plaintiff in this case, CMA has been working with the parties involved over the past several months to reach a fair settlement. Unfortunately, the Blue Shield of California board of directors recently decided it was not willing to pay the pro rata shares owed to doctors who provided tens of millions of dollars in uncompensated care to Blue Shield enrollees.

The case, Rick Love, M.D. v. Blue Cross Blue Shield Association, was filed in May 2003 in federal district court in Miami. The suit accused the insurers of a pattern and practice of denying and delaying care, including intentionally programming computer billing databases to automatically down-code physician claims. The suit was filed under the federal civil RICO (Racketeering Influenced and Corrupt Organizations) statutes.

http://www.calphys.org/html/alert072607.asp?anchorID#3

Comment:

By Don McCanne, MD

Those who believe that private insurers should continue to have a prominent role in health care financing often point to the Blue Cross and Blue Shield companies as effective, efficient and ethical insurers. How has that played out in California?

Blue Cross of California has a well deserved reputation for being the heavy in the havoc wreaked in California’s insurance market. They led the way by transforming themselves from a traditional, non-profit insurer serving patients, into a for-profit insurer serving investors. The ugly story will not be repeated here other than to say that their financial success has been due primarily to their business model that has allowed them to offer competitive premiums by limiting their medical losses. The innumerable devious methods used to avoid paying for health care are what offend our sensibilities.

In contrast, Blue Shield of California, founded by the California Medical Association, has remained non-profit, and has had a reputation a representing the noble traditions of the Blues. But is that reputation deserved?

To remain competitive, Blue Shield had to adopt many of the same nefarious measures that Blue Cross uses to limit medical losses. According to this lawsuit, they established “a pattern and practice of denying and delaying care,” and even resorted to the dishonest practice of using computers to automatically change service code numbers. Thus physicians were not being paid the already-discounted fees for which they contracted. Blue Shield is serving neither the patients nor the providers well. The take-home point is that even the best of the private insurers engage in devious practices.

Physicians and hospitals might have their differences with the Medicare program, but at least reimbursements are determined by an open an honest process (a process that requires continual refinement). More importantly, Medicare policies are designed to promote affordable access to care for everyone qualified, whereas private insurer policies are designed to hinder access to care and to exclude those with the greatest needs.

We really do need to eliminate the inefficient, intrusive private insurers from our health care system. Even the Blues have to go.

Prescription mining raises millions for doctors' group

By Robert Restuccia and Lydia Vaias
San Francisco Chronicle
Wednesday, July 25, 2007

Drug companies care about what your doctor prescribes just as much as you do – and they’re paying big money to find out. They are paying so much, in fact, that even though the vast majority of physicians disapprove of the sale of their personal prescribing data for marketing purposes, the American Medical Association persists in selling detailed physician information to the pharmaceutical industry. This data must be used for legitimate public health research – not brand promotion.

Drug ads cover doctors’ offices, coating everything from wall calendars and paperweights to stethoscopes and prescription pads. The numbers show that these advertisements work: doctors are prescribing more brand-name, higher-cost drugs than ever before.

One of the less obvious but more intrusive marketing tools is the drug rep’s hand-held computer, which contains a detailed profile of your doctor’s prescribing history. Armed with the knowledge of each doctor’s individual prescribing habits, pharmaceutical sales representatives tailor their pitches to each physician. This strategy has resulted in new, costlier drugs replacing established medications that have proven histories of safety and effectiveness. Industry profits swell, as do the nation’s health care costs.

Few people recognize the role the AMA plays in making physician information available to companies that use it for pharmaceutical marketing purposes. The AMA sells information from its physician “Masterfile” to health information organizations that pair the identifying information with prescribing records from pharmacies and sell the whole package to pharmaceutical companies, a practice commonly called “prescription data-mining.”

The AMA profits handsomely from this agreement. In 2005, the AMA made more than $44 million from the sale of database products, approximately 16 percent of its budget. It comes as no surprise, then, that the sale of prescriber information failed to make the formal agenda when AMA delegates met in Chicago last month.

Yet among physicians there is a growing and vigorous debate about the appropriateness of this practice and its enhancement of pharmaceutical marketing. Despite representing less than 30 percent of all U.S. doctors, the AMA keeps identifying information on all licensed physicians – and sells it all. Even so, only 60 percent of physicians surveyed by the Kaiser Family Foundation were aware of the sale of their information. Once told, 74 percent disapproved. Even a survey by the AMA itself found a 66 percent disapproval rate.

A number of policymakers, physician groups and medical societies have come out against this practice in recent years. Leaders include the National Physicians Alliance, the American Medical Student Association, the Vermont Medical Society and the New Hampshire Medical Society. Unfortunately, the AMA has a financial incentive to keep selling this information without regard to how it is being used or the impact it has on patient care and health-care costs.

A growing number of states have taken measures to end data mining because the AMA will not. Maine and Vermont recently passed legislation banning the sale of information detailing what drugs doctors are prescribing their patients while New Hampshire, the first state to pass such legislation, saw the data mining companies challenge the law. A federal court overturned the law banning the sale of prescription information “on free speech” grounds and the case in now being appealed by New Hampshire.

Last year, in response to this growing pressure, the AMA created an “opt-out” measure, called the Prescribing Data Restriction Program. Difficult to navigate, poorly publicized, with only a quarter of physicians are aware of it, and used by less than 1 percent of doctors, the opt-out program is a step toward reform, but a small and inadequate one. The program does not bar the sale of prescriber information to pharmaceutical companies; it merely requests and then relies on the industry to prevent the transmission of this data to its sales teams.

By continuing to profit from the sale of physician data, the AMA has shown itself to be at best, slow-to-act, and at worst, opportunistic at the expense of professional boundaries. The AMA should put medical ethics before profits and stop licensing its Physician Masterfile for pharmaceutical marketing purposes.

Robert Restuccia is the executive director of the Prescription Project, a national initiative supported by the Pew Charitable Trusts to end conflicts of interest created by the pharmaceutical industry’s marketing to physicians. Lydia Vaias serves as president of the National Physicians Alliance and is a board-certified general surgeon on staff at Kaiser Permanente Hospital in Bellflower (Los Angeles County).

This article appeared on page B – 9 of the San Francisco Chronicle