Resource – Page 1069

Getting serious about the economy

By Michael R. Huckleberry
Midland Daily News
10/30/2005

The recent announcement regarding General Motors plan to cut back on health care came as no surprise. The only thing America seems to “win” lately is the “race to the bottom.” Didn’t anyone realize that when “big business” started to outsource our jobs to countries that pay workers so little they cannot buy the products they make this would be inevitable? Big business has not created a trading partner that would bolster our own economy … they turned the “American Dream into the American Nightmare.”

As a small business owner I have no problem understanding that people need good paying jobs with benefits to support their families, small business, and of course, this nation. It is my hope that as we “win this race to the bottom” that my “brothers and sisters” in the business world realize what is happening to them and it isn’t good.

Corporate greed has put our entire nation in danger, and now it is starting to catch up with some of the “big businesses” that helped lead us to this dire situation. We, as a nation of entrepreneurs, skilled laborers, farmers and middle management, are being punished for leading the world in building a strong middle class. Trade agreement that only benefit a few and do not build profitable trade partners will only hasten our “race to the bottom”

There may be a solution to this free fall. First we must vote out of office those who have supported these trade agreements. They are like “Economic Suicide” and our legislators know this! They either have investments in companies that outsource, or they receive large contributions from them, or both.

Second, it is time to get serious about “single payer health insurance”. We simply cannot continue to be in denial about our current health care system. It is a national disgrace. This country has over 45 million people with no health care insurance. High insurance rates are crippling our employers, making it difficult to compete in the current global economy. Of 19 industrialized nations America is the only one without a single payer health care system. It is reported that about 18,000 people died last year in America because they had no insurance. That makes it a moral issue as well. Health savings accounts, and AHP’s and other “gimmicks” that are being promoted by some legislators don’t cut it. Some are being promoted because, once again, of heavy contributions and stock ownership. Who is against single payer health insurance? … insurance companies, drug companies, politicians who benefit, and the extreme right who scream “socialized medicine”.

We are not talking about socialized medicine, we are talking about saving America with an insurance program that is fully funded. The “far right” fought us every step of the way when we wanted Social Security, Medicare, and Medicaid. When we finally got them, we shared them with everyone. I am sure someone in your family has benefited from these insurance programs. These programs have kept us from having a third world standard of living, and they work well when properly managed and funded.

This new prescription section of the Medicare bill that the “far right” has imposed on us has no provision to pay for it and no provision to negotiate for lower drug prices. That is socialized medicine, and more debt for our nation. Who’s tax dollars are they looking out for?

I believe that “single payer health insurance” is the number one way to kick start our economy.

We must act now, as our nation’s future depends on it.

Michael R. Huckleberryis a candidate for 4th District U.S. House. He lives in Greenville.

Krugman’s solution for employment-based health insurance

Pride, Prejudice, Insurance
By Paul Krugman
The New York Times
November 7, 2005

Employment-based health insurance is the only serious source of coverage for Americans too young to receive Medicare and insufficiently destitute to receive Medicaid, but it’s an institution in decline. Between 2000 and 2004 the number of Americans under 65 rose by 10 million. Yet the number of nonelderly Americans covered by employment-based insurance fell by 4.9 million.

The funny thing is that the solution – national health insurance, available to everyone – is obvious. But to see the obvious we’ll have to overcome pride – the unwarranted belief that America has nothing to learn from other countries – and prejudice – the equally unwarranted belief, driven by ideology, that private insurance is more efficient than public insurance.

The U.S. system is much more bureaucratic, with much higher administrative costs, than those of other countries, because private insurers and other players work hard at trying not to pay for medical care.

The economic and moral case for health care reform in America, reform that would make us less different from other advanced countries, is overwhelming.
One of these days we’ll realize that our semiprivatized system isn’t just unfair, it’s far less efficient than a straightforward system of guaranteed health insurance.

http://select.nytimes.com/2005/11/07/opinion/07krugman.html?hp

Comment: Although most are familiar with Paul Krugman’s column in The New York Times, some may not be aware that he is a Professor of Economics at Princeton. He received his Ph.D. from MIT, and has taught at Princeton, Yale, MIT and Stanford. The point is that he thoroughly understands the economic case for national health insurance. Our task is to make sure that everyone else does too.

The safety net is tattered

Kaiser Commission on Medicaid and the Uninsured
November 4, 2005

Covering the Uninsured – Growing Need, Strained Resources

In 2004, America’s 46 million uninsured received about $41 billion dollars in uncompensated care – care that was not paid for either by the uninsured themselves or by another identifiable source. Most of the care received by the uninsured is provided through the informal network of hospitals, clinics, and health centers, referred to as the “safety net,” which is supported by federal, state, and local government as well as private sources. About half of all safety net funds come from the federal government, but they still comprise less than one percent of overall federal spending.

After adjusting for medical inflation and using constant 2004 dollars, total federal spending on the safety net increased by only slightly more than one percent between 2001 and 2004. Because the number of uninsured grew by nearly 5 million people, federal spending actually decreased from $546 to $498 per uninsured person over this time – a decline of 8.9%.

The federal commitment to the health care safety net has not kept pace with the growth in the uninsured, and future federal funding appears unlikely to reverse this trend. Most federal safety net spending flows through Medicare and Medicaid, both of which are under severe budgetary pressures. If safety net resources continue to decrease as the number of uninsured increases, the amount of care provided to the uninsured will be jeopardized, with further consequences on their health and the health of the country.

http://www.kff.org/uninsured/upload/Covering-the-Uninsured-Growing-Need-Strained-Resources-Fact-Sheet.pdf

The Uninsured and Their Access to Health Care

Charitable physicians and the safety net of community clinics and public hospitals do not fully substitute for health insurance. Lack of health coverage matters for millions of uninsured Americans – affecting their access to care, health status, job decisions, and financial security, as well as exacting an indirect toll on society in terms of more disability, lower productivity, and increased burden on the health care system.

http://www.kff.org/uninsured/upload/The-Uninsured-and-Their-Access-to-Health-Care-Fact-Sheet-6.pdf

Five New Reports Profile the Growing Uninsured Population and Portray the Health Care Safety Net as Increasingly Strained:
http://www.kff.org/uninsured/kcmu110405pkg.cfm

Comment: Lacking the “insurance ticket” that authorizes access to the private health care delivery system, the uninsured must depend on the safety net. When you consider that premiums for employer-based coverage for an individual averaged $3481 in 2003, it is difficult to imagine that the current safety net federal spending of $498 will pay for much care for the uninsured who typically have greater needs than the higher-income, healthier work force.

Since programs for safety net funding are considered to be welfare programs, the weak political voice for the uninsured is always drowned out by the strong political voices calling for fiscal restraint. Safety net institutions will never receive adequate funding until they are included in a single, universal risk pool.

We will always need community health centers and public hospitals. But to fund them adequately we will need to establish a program of comprehensive, universal health insurance, with everybody in, nobody out.

Health systems provide mediocrity for sicker adults

Taking The Pulse Of Health Care Systems: Experiences Of Patients With Health Problems In Six Countries
By Cathy Schoen, Robin Osborn, Phuong Trang Huynh, Michelle Doty, Kinga Zapert, Jordan Peugh, Karen Davis
Health Affairs
November 3, 2005

This paper reports on a 2005 survey of sicker adults in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States. Sizable shares of patients in all six countries report safety risks, poor care coordination, and deficiencies in care for chronic conditions. The United States often stands out for inefficient care and errors and is an outlier on access/cost barriers.

As found in past surveys, the United States is an outlier for financial burdens on patients and patients forgoing care because of costs. Half of sicker adults in the United States said that they did not see a doctor when sick, did not get recommended treatment, or did not fill a prescription because of cost. On each access/cost question, the U.S. rate was 1.5 to double the forgone care rates reported in the next-highest country.

Moreover, the percentage of U.S. sicker adults forgoing care because of costs was much higher on all three indicators compared with the 2002 survey of sicker adults. Despite these high rates of care forgone, one-third of U.S. patients spent more than $1,000 out of pocket in the past year, a level rare in the other countries. Insured and uninsured U.S. patients were about equally likely to report expenditures this high (34 percent insured and 32 percent uninsured).

Symptoms of inadequate insurance coverage and more fragmented care in the United States emerged throughout the survey. The United States outspends the other countries, spending 14.6 percent of national income compared with Germany’s 10.9 percent, Canada’s 9.6 percent, Australia’s 9.1 percent, New Zealand’s 8.5 percent, and the United Kingdom’s 7.7 percent. Yet the United States often ranks last or tied for last for safety, efficiency, and access.

With one-third of U.S. patients reporting medical, medication, or lab errors and a similar share citing duplicate tests or medical record delays, our findings indicate widespread performance deficiencies that put patients at risk and undermine care. Moreover, a recent study finds that the United States is not systematically a leader in clinical outcomes.

Confirming spending data from the Organization for Economic Cooperation and Development (OECD), the United States also stands out for its patient cost burdens, with consequences for access. U.S. physician visit rates are already low by OECD standards. To the extent that U.S. insurance continues to move toward higher front-end patient deductibles, these rates could go up, as increasing numbers of insured patients become “underinsured,” lacking access or adequate financial protection. Contrasts between the United States and Germany, in particular, indicate that it is possible to organize care and insurance to achieve timely access without queues, while ensuring that care is affordable at the point of service. There are clear opportunities for the United States to learn from other countries’ insurance systems.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.509v1

Release from The Commonwealth Fund:
http://www.cmwf.org/publications/publications_show.htm?doc_id=313012&#doc313012

Comment: This is yet another report that confirms that the United States does not have “the greatest health care system on earth,” even though we are paying enough such that we should have it. Our lowest ratings in these international comparisons stem from our fragmented system of funding care.

We can learn much from other countries’ insurance systems. Combining optimal insurance policies with our great resources should provide the first giant step toward providing us with what would truly be the greatest health care system on earth.

Working-Age Americans Bear Brunt of Medical Debt

Health Care Economics
By Rich Daly
Psychiatric News
October 21, 2005
Volume 40, Number 20, page 16
© 2005 American Psychiatric Association

A study finds the largest number yet of Americans struggling with medical bills and medical debt. The burden deters many from seeking preventive care and chronic disease treatment.

Nearly one-third of working-age Americans struggle to pay their medical bills, according to a recent report, with African Americans and women the most financially strained.

A recently released analysis of the 2003 Commonwealth Fund Biennial Health Insurance Survey concluded that an estimated 77 million adult Americans-both insured and uninsured-have difficulty paying medical bills, have accrued medical debt, or both. The latest findings support the conclusions of earlier studies that have found medical debt to be a significant problem, even for those with health insurance (Psychiatric News, March 18).

“Medical bill and debt problems not only create financial hardship but can deter people from seeking further health care,” said Michelle McEvoy Doty, Ph.D., a study author and senior analyst at the Commonwealth Fund. “In the long run that situation puts a bigger burden on the health care system because you are missing out on preventive medicine and not managing chronic conditions.”

Working-age adults are much more likely to face medical bill problems than Americans aged 65 and older, since pensions and Medicare offer protections for older Americans. The survey found that nearly one-third of the working-age respondents (32 percent) reported struggles with medical bills, while just 14 percent of elderly respondents reported the same. Medical debt was reported by 16 percent of working-age adults compared with 4 percent among adults over 64 years old.

Doty said the larger impact of medical bills on working-age adults stems from private insurers’ “much more fragmented” approach to coverage, compared with Medicare’s “very reliable” assistance in paying medical bills.

The challenge for working adults trying to pay for health care was even greater than for seniors among those with low incomes. The report found that 48 percent of low-income, working-age adults reported medical bill problems in the 12 months prior to the survey, while only 20 percent of low-income seniors reported such problems.

Working-age women were strongly impacted by the cost of medical care, and 39 percent reported medical bill problems, compared with 25 percent of men.

The survey found that 52 percent of African Americans reported medical bill problems, in contrast to 34 percent of Hispanics and 28 percent of whites, according to the report.

The data stem from a national telephone survey conducted from September 3, 2003, through January 4, 2004, among a random, nationally representative sample of 4,052 U.S. adults. The survey had a 50 percent response rate.

Access Under Increasing Threat

Health care reform advocates, such as Physicians for a National Health Program (PNHP), said the data support long-held beliefs that the rising cost of health care reduces access to that care, especially among working-age Americans, who lack the Medicare or pension coverage that buffers costs for older Americans.

“Though some protection for the retired is afforded by pension funds, the much larger incomes of the workforce are not adequate to compensate for the deficiencies of private coverage,” according to a statement on the results issued by PNHP, which advocates a national, single-payer health system. “Obviously a universal Medicare program with expanded benefits would be much more effective in preventing medical debt.”

Crisis Acute for Uninsured

Those without health insurance coverage during the study period had significantly higher rates of medical bill problems and debt (60 percent) than did the continuously insured (35 percent).

Rates of medical bill problems for the uninsured were more than twice those of the insured, with 35 percent of those without insurance at some point in the year contacted by collection agents compared with 15 percent of the continuously insured.

However, the possession of health insurance was not enough to prevent large numbers of Americans from incurring a large burden of medical debt. Researchers found that 57 percent of adults with medical bill problems and 70 percent with medical debt were insured at the time their financial obligation was incurred.

“As employers continue to pass on health care costs to their employees, you are going to see more people struggling with their medical bills and accruing debt,” Doty said.

A survey of 1,800 firms released in September by Mercer Human Resources Consulting found more employers are struggling with ways to cover what is expected to be a nearly 10 percent increase in health insurance costs for 2006 and plan to shift more of the burden of paying for medical care to their employees. Despite the expected 10 percent increase, employers polled plan to increase their spending by only 6.4 percent and have their employees make up the difference.

Medical bill problems and inadequate insurance, said the Commonwealth survey analysis, were also linked by inadequate or absent prescription drug coverage. Nearly half of working-age adults without prescription coverage in their insurance plan had problems covering the medical costs, compared with one-third who did have prescription drug benefits.

The study also found that medical bill burdens and medical debt reduced Americans’ access to health care, with 63 percent of adults with medical debt problems forgoing needed care within the preceding year due to cost. Only 19 percent of adults without medical bill challenges avoided seeking needed health care.

The study found 43 percent of workingage adults experiencing medical bill or debt problems failed to fill a prescription because of cost, compared with just 9 percent of adults not enduring such problems.

Even after adjusting for insurance coverage, income, health status, and other variables, the researchers found that Americans with problems paying health care bills were much more likely to leave a prescription unfilled, forgo a needed physician’s visit, or skip recommended tests or follow-up visits than were adults less challenged by medical costs.

The study found as well that 23 percent of those struggling to pay medical bills did not see a specialist when needed, compared with 6 percent without such bill-paying challenges. Thirty-seven percent with medical bill problems skipped medical tests, treatment, or follow-up, while only 6 percent of those without bill problems did so.

Additionally, 42 percent of those with daunting medical bills had a medical problem but did not visit a physician or clinic for treatment, far more than the 8 percent without difficult medical bills and did not seek needed assistance.

“People who have bills and debt are more likely to have health care access problems,” Doty said.

Lack of health insurance kills

By Kay Lapp James
November 2, 2005
Wisconsin Dells

Being without health insurance can kill you, say Drs. Linda and Gene Farley, and access to medical care should be a right, not a privilege.

The two doctors spoke on the health care crisis and the need for a national health care plan at a meeting Thursday of the Dells Progressive Voices. About 20 people heard the Farleys describe with numbers and anecdotes the plight of the uninsured in America.

The two retired University of Wisconsin-Madison Medical School faculty members also were once family practice doctors and believe the country can afford to provide medical care to everyone.

Gene Farley asked anyone who does not believe health care is a right to say on whose doorstep the uninsured will die.

The uninsured die because they don’t have insurance, said Linda Farley. In 2002, 18,314 adults died because they did not have insurance and could not afford medical care.

U.S. taxpayers pay the health care bill for about 50 percent of the U.S. population through Medicare for seniors, veterans, Native Americans, Medicaid for the disabled, children and the poor elderly, and for public employees on the local, state and national level. Of the rest of the population, 45 million don’t have any insurance. Of those without insurance, 50 percent are employed and 25 percent are children.

While Americans may brag about the quality of care here, Linda Farley pointed to comparisons showing that the United States had poorer life outcomes than countries with national health care plans.

The U.S. had the highest infant mortality rate in 1999 (7.1 babies per 1,000 births)among a group of developed countries, that comprises Australia, Canada, Italy, Germany, France and Sweden.

In that same year and among those same countries, women lived fewer years in the United States. Here women can expect to live an average of 79 years, while in France they can live an average of about four more years.

“Every other industrialized nation (except the United States) has a healthcare system that assures medical care for all,” said Linda Farley.

Those countries also spend less than the United States does per person. Most spend less than half what the U.S. does, she said.

Besides the lower death rates, those countries also have more accountability for care and higher satisfaction with care, she said.

The way to cut costs and to insure everyone is to go with a one-payer health care system, the couple said. That eliminates the most costly feature of the U.S. health care system half the multiple payers: insurance companies, HMOs, PPOs and the government.

As an example of the savings that could be achieved, the Farleys compared the same size hospitals in the United States and in Canada. In the U.S., a patient bill must cover the costs of 356 people in the billing department, which adds about $372 to each bill. In Canada, the same size hospital needs just nine people in its billing department and billing adds $68 to a patient’s bill.

In addition to a more cumbersome billing process, hospitals and other medical facilities have been adding administrators. Since the 1970s, the number of administrators has grown by 2,500 percent while the number of registered nurses in hospitals has hardly grown. The growth of the clerical staff has spawned the increase in administration.

Linda Farley also pointed to the salaries of the CEOs of health insurance and managed care companies. The salaries start around $1 million and the highest, $5 million, goes to the CEO of Cigna, Wilson Taylor. Those salaries don’t include the stocks the CEOs also receive. Taylor also receives $64.2 million in stock.

The Farleys also cited drug manufacturers as contributing the high cost of health care. In a chart, they showed that drug companies spend 27 percent of their income on manufacturing, 35 percent on administration and marketing, 7 percent on taxes and only 13 percent on research and development. A drug manufacturer has profits of about 18 percent, Linda Farley said, which was much more than the average Fortune 500 company. It makes about 5 percent profit.

Doctors’ salaries are less of a problem, although some who have become partners in hospitals, clinics and insurance organizations have become millionaires. Gene Farley noted that when Medicare began in the 1960s, doctors’ incomes began to rise. Prior to that time, health care was considered a charity and doctors often weren’t paid for the care they provided. With Medicare, doctors could count on being paid.

“People say we can’t afford universal care, but we’re already paying for it,” Gene Farley said.

Bills to set up a universal or single-payer system in Wisconsin have been introduced in the state Legislature. Under such a system, the Farleys said the state could save money. In 2003, spending here for health administration totaled $7.72 billion. They say that a single-payer health insurance would have saved $5.52 billion or enough to provide $13,513 for each of the 409,000 uninsured people in the state.

Gene Farley said he does not understand why businesses here do not support a single-payer, universal health care system. Canadian businesses have cheaper operating costs because of the universal system there and support it. In Canada, every business has to pay into the system.

The United States or even Wisconsin won’t get a single-payer system unless people demand it, Gene Farley said. He urged people to be noisy and contact their legislators. He also urged everyone to vote, noting that poor people who pay the steepest price for health care (they get no discounts like the government and HMOs or PPOs get) don’t vote.

“It won’t get any better until people speak up,” said Gene Farley.

International Survey: U.S. Leads In Medical Errors

PRESS RELEASE

EMBARGOED UNTIL
Thursday, November 3, 2005, 9:00 A.M. EST (Washington and Ottawa) Thursday, November 3, 2005, 2:00 P.M. GMT (London) Thursday, November 3, 2005, 3:00 P.M. CET (Berlin) Friday, November 4, 2005, 1:00 A.M. (Canberra) Friday, November 4, 2005, 3:00 A.M. (Wellington)

For further information, contact:
Mary Mahon, (212) 606-3853 or (917) 225-2314, mm@cmwf.org, or Monika Ellis, (301) 652-1558, mellis@burnesscommunications.com

International Survey: U.S. Leads In Medical Errors

Patients in Six Nations Report High Error Rates, Lapses In Hospital Discharge Planning, And Lack Of Care Coordination

U.S. Has Highest Out-Of-Pocket Expenses And Rates Of Forgone Care Due To Costs

Bethesda, MD — One-third of patients with health problems in the United States report experiencing medical, medication, or test errors, the highest rate of any nation in a new Commonwealth Fund international survey. Assessing health care access, safety, and care coordination in Australia, Canada, Germany, New Zealand, the United Kingdom, and the United States, the survey found that while no one nation was best or worst overall, the United States stood out for high error rates, inefficient coordination of care, and high out-of-pocket costs leading to barriers to access to care.

The findings are published today in a Health Affairs article, “Taking the Pulse of Health Care Systems: Experiences of Patients with Health Problems in Six Countries,” whose lead author is Commonwealth Fund senior vice president Cathy Schoen.

You can read the article at http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.509.

“While the consistently high error rates and lack of coordination are disturbing, the findings also highlight the potential for each country to improve,” said Commonwealth Fund president Karen Davis. “Some countries have been able to achieve timely access to needed care while reducing financial barriers. Each country could also gain through strategies to improve the quality and efficiency of care, such as implementing modern information technology systems, supporting patient engagement in care, and improving management of chronic conditions.”

The 2005 survey of adults with health problems is the eighth in an annual series of cross-national surveys conducted by Harris Interactive for the Commonwealth Fund.

One-third (34 percent) of U.S. survey participants reported at least one of four types of errors: They believed that they experienced a medical mistake in treatment or care, were given the wrong medication or dose, were given incorrect results for a test, or experienced delays in being notified about abnormal test results. Three of ten Canadian respondents reported at least one of these errors, as did one-fifth or more of patients in Australia (27 percent), New Zealand (25 percent), Germany (23 percent), and the United Kingdom (22 percent).

U.S. patients who saw four or more doctors in the past two years were especially vulnerable, with about half reporting at least one of these errors; this points toward lapses in communication during care transitions.

Although attention to patient safety has focused chiefly on care in hospitals, a majority of patients (60 percent or more) in each country who reported medical mistakes or medical errors said that these errors occurred outside the hospital, which highlights the need for policies to improve patient safety in ambulatory care settings.

“There were many symptoms of poorly coordinated care in every country, regardless of the type of delivery or financing system,” said Schoen. “Shortfalls were particularly evident for people when discharged from the hospital, and for patients seeing multiple physicians. Improved care coordination during transitions across sites of care and providers offer opportunities for significant improvement. These patients are the ‘canary in the coal mine’ of any health system.”

In all six countries, one-third or more of recently hospitalized patients reported failures to coordinate care during hospital discharge. Germany had the highest rate of patients reporting lack of follow-up care, with three-fifths (60 percent) saying that the hospital did not make arrangements for follow-up visits with a doctor or other health professional or otherwise give instructions about posthospital care, such as symptoms to watch for and when to seek further care.

The United States had the highest rate of patients reporting coordination-of-care problems that reflected inefficient care during doctor visits. One-third of U.S. respondents said that within the past two years, either their test results or records were not available at the time of a doctor’s appointment, or that a doctor had ordered a test that had already been done. Rates of care-coordination problems in the United States were higher than those in the other five countries, which ranged between about one-fifth to one-quarter reporting coordination problems.

Patients with chronic diseases in all of the countries often did not receive the care recommended to manage their condition. At best, about half of diabetics reported receiving all four recommended screening exams to manage their condition. Patients who had supports such as a self-management plan or a nurse included as part of their care management team were more likely than others to have received recommended care.

The United States was an outlier for its financial burdens on patients:
• Half of U.S. adults reported that they had gone without care because of costs in the past year
• In contrast, just thirteen percent of U.K. adults reported not getting needed care because of cost
• One-third of U.S. patients reported out-of-pocket expenses greater than $1,000 in the past year
• U.K. patients were the most protected from high cost burdens, with two-thirds having no out-of-pocket expenses. The variations were notable given the study’s design focus on sicker adults with recent intensive use of medical care.

Access—including after-hours access—and waiting times to see a doctor when sick differed markedly across the countries:
• Canadian and U.S. adults who needed medical care were the least likely to report fast access (same day) to doctors (30 percent or fewer of U.S. or Canadian patients)
• In contrast, majorities of patients in New Zealand (58 percent) and Germany (56 percent) reported that they were able to get same-day appointments, as did nearly half of patients in Australia (49 percent) and the United Kingdom (45 percent)
• Majorities of patients in Germany (72 percent), New Zealand (70 percent), and the United Kingdom (57 percent) also reported easy after-hours (nights, weekends, or holidays) access to a doctor
• In contrast, majorities of patients in the United States (60 percent), Australia (58 percent), and Canada (53 percent) said that it was very or somewhat difficult to get after-hours care
• The four countries with comparatively more rapid access to physicians—Australia, Germany, New Zealand, and the United Kingdom—also had lower rates of emergency room use, with Germany having the lowest rates
• One-fifth of Canadians and one-fourth of U.S. patients who reported going to the ER said that it was for a condition that could have been treated by their regular doctor if available

The findings highlight the need for improved access as well as coordination of care. The authors conclude that “these findings suggest that many of the problems with which policy leaders are grappling transcend specific payment or delivery systems and will require more fundamental transformation.”

The Commonwealth Fund is a private foundation supporting independent research on health care issues and making grants to improve health care practice and policy.

Health Affairs , published by Project HOPE, is the leading journal of health policy. The peer-reviewed journal appears bimonthly in print with additional online-only papers published weekly as Health Affairs Web Exclusives at www.healthaffairs.org. The full text of each Health Affairs Web Exclusive is available free of charge to all Web site visitors for a two-week period following posting, after which it will switch to pay-per-view for nonsubscribers. The abstracts of all articles are free in perpetuity. Web Exclusives are supported in part by a grant from the Commonwealth Fund.

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Unintended over-utilization by ethical physicians

Variation in the Tendency of Primary Care Physicians to Intervene
By Brenda E. Sirovich, MD, MS; Daniel J. Gottlieb, MS; H. Gilbert Welch, MD, MPH; Elliott S. Fisher, MD, MPH
Archives of Internal Medicine
October 24, 2005

There is widespread recognition that health care spending varies widely across the United States. Per capita Medicare expenditure in the areas of highest spending is double that in the lowest-spending areas, even though in some cases these represent neighboring areas. Because higher spending does not appear to result in better outcomes or quality of care, there is intense interest in understanding the reasons for the wide variation in utilization of services. Average illness severity varies little across regions; therefore, attention has focused increasingly on the role of physicians who, through their actions and recommendations, control most health care resources and thereby direct most health care spending.

There are, however, competing explanations of how physicians might contribute to higher health care spending. On the one hand, high-spending areas have more physicians per capita, and on average, patients in these areas each see a greater number of physicians. Even if each physician’s shared ordering pattern is identical to those in lower-spending areas, utilization (and spending) per capita would be higher in areas with a greater number of physicians. On the other hand, physicians in high- and low-spending regions may have entirely different ordering patterns.

Specifically, physicians in high-spending areas may be more prone to intervene – to order tests, referrals, and treatments – for individual patients.

We sought to determine whether physician behavior is at least in part responsible for widely varying spending and utilization patterns across the United States – that is, to what extent individual physicians in high-spending regions have a greater tendency to intervene for individual patients.

The sample of primary care physicians consisted of both family/general practitioners (57%) and general internists (43%). Regions in the quintile of highest spending averaged $8325 per capita in annual Medicare spending and
242 physicians per 100,000 persons compared with $6087 per capita and 193 physicians per 100,000 in moderate-spending regions and $4911 per capita and 185 physicians per 100,000 in regions of low spending. The supply of hospital beds and physicians of all specialties was more abundant in regions of higher spending, with the exception of family practitioners, whose numbers declined as local spending increased.

This study shows that widely differing levels of health care spending across the United States reflect the tendency of local physicians to recommend interventions for patients. In high-spending areas, physicians would order further evaluation or treatment for approximately 10 additional patients of every 100 patients seen compared with physicians in low-spending areas.

While we have shown that physicians who practice in areas of higher local health care spending are more prone to intervene, we are unable to distinguish among 3 potential explanations: (1) more aggressive physicians may be attracted to certain areas; (2) physicians may adopt the practice style (or standard of practice) of the community where they locate; or (3) characteristics of the market itself, such as greater difficulty maintaining target incomes in a more competitive marketplace, could lead to a lower threshold for referral and test ordering.

It is unlikely that physician behavior is the sole explanation for higher levels of spending in some areas. Having more specialists or more hospital beds in an area, for example, likely plays a role in higher levels of local spending. It is also possible that – notwithstanding similar end-of-life preferences – differences in patient expectations and demands across different regions impact the level of local health care spending via direct influence on physician decision making. However, in the present study we have been able to show that, when faced with the same patients, physicians in higher-spending areas are more likely to intervene, and this undoubtedly accounts for some portion of the higher spending seen in some US regions.

http://archinte.ama-assn.org/cgi/content/abstract/165/19/2252

Comment: We already know that there is a wide variation in spending in different locations, and that the differences are not explained by the relative health of the populations served. We know that the higher level of spending does not result in higher quality nor does it improve health outcomes. We know that regions with higher spending have excess capacity and an excess concentration of specialists. This study adds to others which demonstrate that physician behavior also drives up spending in high-cost areas.

The design of this study makes it very likely that these physicians believe that they are making optimal choices for their patients’ care. As we consider policy changes that would reduce excess spending in high-cost areas, it is a relief to know that not much attention needs to be directed to efforts to reduce fraud and abuse (except for the rare provider who clearly churns or submits fraudulent claims).

A single payer system can be beneficial because, as a monopsonistic purchaser, it can favorably alter the practice environment. Excess capacity of health care facilities can be controlled through budgeting of capital improvements. Excess concentration of specialists can be controlled by offering differential compensation based on regional needs.

Controlling excess capacity runs the risk of creating excessive queues. Continual monitoring with appropriate adjustments as needed would be required. Not only would we benefit by reducing the waste of over-utilization, but we would also improve access in regions with deficient capacity.

Those who are uncomfortable with a publicly administered process should keep in mind that currently the marketplace is failing to provide the oversight and adjustments that need to be made. We want to continue to spend nearly the same amount on health care, but we want to spend it much better.

Kentucky AFL-CIO Endorses Conyers' Single Payer HR 676

Adopted by the Kentucky State AFL-CIO Convention, October, 2005
RESOLUTION CALLING FOR THE KENTUCKY STATE AFL-CIO CONVENTION TO ENDORSE HR 676, SINGLE-PAYER UNIVERSAL HEALTH CARE

Workers, their families and their union are waging an increasingly difficult struggle to win or keep good health care coverage. Almost very union at every contract deadline must battle and sacrifice merely to sustain health care benefits. The rising costs of health insurance are blocking workers’ progress in wages and other areas. All of our unions face a health care crisis.

But the crisis extends far beyond union members. More than 45 million people in the U.S. are currently without health care insurance. More than 75 million went without for some length of time within the last two (2) years; and millions more have inadequate coverage or are at risk of losing their coverage. Women, people of color and immigrants are denied care at disproportionate rates, while the elderly and many others must choose between the necessities and life sustaining drugs and care. Unorganized employers, such as Wal-Mart dump their responsibilities for health care onto public programs.

The U.S. health system continues to treat health care as a commodity distributed according to the ability to pay, rather than a social service to be distributed according to human need. Insurance companies and HMOs compete not by increasing quality or lowering costs, but by avoiding covering those with the greatest need.

Economic necessity and moral conscience compel us to seek a better way. Therefore, be it resolved that: A single payer program as provided for in Congressman John Conyers’ bill HR 676, ‘Expanded and Improved Medicare for All,’ a single payer health care program is the only affordable option for universal, comprehensive coverage.

That the Kentucky State AFL-CIO will work with unions and community groups to build a groundswell of popular support and action for single payer universal health care and HR 676 until we make what is morally right for our nation into what is also politically possible.

That the Kentucky State AFL-CIO will send a copy of this resolution to Congressman Conyers, to all the Kentucky members of the U.S. House and Senate, to the AFL-CIO Executive Committee, and to the news media.

Respectfully submitted by,

AFSCME Local 2629

Sheila Wade, President

Kentucky AFL-CIO Endorses Conyers’ Single Payer HR 676

Adopted by the Kentucky State AFL-CIO Convention, October, 2005
RESOLUTION CALLING FOR THE KENTUCKY STATE AFL-CIO CONVENTION TO ENDORSE HR 676, SINGLE-PAYER UNIVERSAL HEALTH CARE

Respectfully submitted by,

AFSCME Local 2629

Sheila Wade, President

Increase in uninsured will save our economy

Changes In Economic Conditions And Health Insurance Coverage, 2000-2004
By John Holahan and Allison Cook
Health Affairs
November 1, 2005

Between 2000 and 2004, the number of uninsured Americans increased by six million, primarily because of a decline in employer-sponsored insurance. All of the increase occurred among adults, for whom the drop in employer coverage was not offset by an increase in public coverage. The number of uninsured children fell slightly. About two-thirds of the growth in the uninsured was among Americans below 200 percent of the federal poverty level. Coverage rates have also fallen among higher-income Americans. About half of the growth in the uninsured was among young adults ages 19-34, about 55 percent among whites, and 73 percent among native-born citizens.

The decline in employer coverage is likely to continue. Increases in health care costs, and thus health insurance premiums, are likely to continue to grow faster than workers’ earnings. The decline in employer coverage will be further exacerbated if the shift from working in large and midsize firms to small firms and self-employment and from high- to low-coverage industries continues. The problem of the uninsured can be addressed in many different ways, such as tax credits or public program expansions, but doing so is likely to prove very difficult. Federal budget deficits are large, which will limit the federal government’s ability to act for the foreseeable future, and all indications are that the government will pursue spending cuts to address the huge cost of hurricane recovery in the coming years.

States also face serious budget problems in part because increases in health care spending outpace the growth in state revenues, a trend that is likely to continue. As a result, it is difficult to envision a reversal of the trends we have described in this paper.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.498v1

Comment: So employment-based coverage is declining, and the increases in the numbers of uninsured cannot be addressed because federal and state spending must be cut. What? Why is that last statement presented as if it were an immutable given?

We do have the option of moving health care spending from private ledgers to public budgets. Yes, there would be challenges in a publicly-budgeted system. In using public funds we would have to be certain that everyone was covered, and that access and funding would be on an equitable basis. But that really wouldn’t be much of a challenge for a single payer system since it would achieve precisely those goals by design.

As the problem gets worse, tens of thousands more will die. Yet we do nothing because one individual says, “No new taxes.” Isn’t there a higher ethical principle that should guide us?

The danger of consumer-driven health care

The Danger of Consumer-Driven Health Care Crash Course
by Jonathan Cohn
The New Republic
Nov. 7, 2005

Health care operates by what economists commonly call an “80/20” rule. In any given year, most of the money being spent on medical care in the United States (about 80 percent of the total) is for the relatively small portion of Americans (about 20 percent of the population) recovering from severe accidents, fighting off a life-threatening disease like cancer, or struggling with a serious chronic condition like diabetes.

… traditional health insurance spreads the financial burden, using premiums paid by people who don’t use many medical services to help pay the bills of those who do. The trouble with HSAs is that they change the equation, dramatically, allowing people in relatively good health to keep much more of their own money. “One hundred percent of the time it makes sense for a healthy person to take the savings account,” one benefits consultant explained in The Tampa Tribune. “That’s a no-brainer.” But, once that happens, there’s less money to subsidize care for the people with high medical bills–which means those people must either make up the difference themselves or simply go without care. “A wholesale switch to [HSAs] would redistribute the nation’s overall financial burden of health care from the budgets of chronically healthy families to those of chronically ill families,” Princeton economist Uwe Reinhardt has written. “One should simply not brush these ethical issues aside.”

…we need to go back to the guiding principle of group health care–that the way to both lower costs and serve as many Americans as possible is to broaden, rather than shrink, the patient pool. One way to do this is through the plan we’ve been flirting with since the Progressive era–universal health coverage. These days, the case for it seems stronger than ever.

Depending on how it’s structured, universal health care would either limit or eliminate altogether the employers’ responsibility for their workers’ health bills, by transferring greater financial responsibility to an even broader base: the entire population, through some combination of taxes and premiums.

(Jonathan Cohn is a senior editor at The New Republic. He is currently writing a book on the U.S. health-care system.)

http://www.tnr.com/user/nregi.mhtml?i=20051107&s=cohn110705&pt=5%2FcM70%2FKqHd9828cDSfJPW%3D%3D

Comment: The full article is well worth reading for those who want an excellent crash course on the danger of consumer-directed health care.

We are looking forward to the publication of Jonathan Cohn’s new book on the U.S. health-care system. Now, more than ever, there is a greater need for more light and less heat on the subject.

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