PNHP

Medicare catastrophic drug coverage is a catastrophe

Medicare catastrophic drug coverage is a catastrophe

Medicare Drug Benefit May Expand ‘Catastrophic’ Protection
By Karen Pallarito
Forbes.com
Oct. 26, 2005

The number of seniors protected against formidably high drug costs will increase sharply under the new Medicare prescription drug program, a new analysis finds.

The study focused on the 1.5 million Medicare beneficiaries in the United States who spend more than $4,000 annually on prescription drugs and who lack coverage for so-called “catastrophic” drug costs. These people include individuals who do not have supplemental drug coverage or whose “medigap” insurance does not pay for prescription drugs

“There’s no question of the impact this benefit will have on the lives of those who are dealing with serious illness and their accompanying prescription drug costs,” said Mary R. Grealy, who chairs the Medicare Today partnership. “Our task is simply to get the word out.”

But Robert M. Hayes, president of the Medicare Rights Center, a New York City-based information and consumer advocacy group, said the numbers are somewhat misleading.

“The point of a real Medicare drug benefit would be to assist folks who go without that medication because they cannot afford the $4,000,” he said.

http://www.forbes.com/lifestyle/health/feeds/hscout/
2005/10/26/hscout528779.html

And…

Medicare Prescription Drug Benefit Calculator
The Lewin Group

(The following is an example entered by The Lewin Group to demonstrate the use of the calculator, but you must click “calculate” to get correct results for the example entered.)

Information entered:
$6,000 – Your individual annual drug costs $25,000 – Your annual household income Single – Marital status

Calculated results:
$1,200 – Estimated savings due to Rx plan’s buying discounts $1,500 – Medicare Rx plan’s share of drug costs $3,300 – Your out-of-pocket costs under the new benefit $3,720 – Your costs including estimated premium

The calculator assumes savings to beneficiaries of 20% resulting from bulk purchasing of prescription drugs, compared to the retail prices many seniors face today as individual cash purchasers.

http://webstudies.lewin.com/pdb/medicare2.htm

Comment: Wow! $2,280 savings for $6,000 worth of drugs. Who could ever complain about that?

Before looking closer at these numbers, it’s important to understand that the Medicare drug benefit was carefully designed to advance the conservative agenda of privatizing Medicare. They wanted to allow drug coverage only under the private Medicare Advantage plans to give them a competitive advantage over the traditional Medicare program. But political realities were such that they had to develop some sort of a Medicare D option to provide drug coverage for those remaining in the traditional Medicare program. Otherwise, the Medicare privatization legislation was doomed to certain defeat.

In order to embed the privatization agenda into the public Medicare D program, the conservatives required that the program be administered privately, through insurers and pharmacy benefit managers. They recognized that this private sector drug bureaucracy would consume much of the negotiated discounts because of their very high administrative costs. If Medicare were allowed to negotiate the same discounts, then the entire scheme would fall apart because Medicare would have been granted an “unfair” competitive advantage because of its greater efficiency. Consequently, the conservatives inserted into the legislation a prohibition against government-negotiated drug discounts. Now, let’s look at the numbers.

Suppose Medicare had been allowed to negotiate discounts. The amount of the discount should be greater since the much higher volume of drug utilization would increase drug costs by only the marginal costs of increasing manufacturing volume, a very small percentage of the overall costs for the pharmaceutical industry. But lets ignore this additional savings and assume that Medicare would receive the same discount as the private pharmacy benefit managers, estimated by The Lewin Group to be 20%.

In the example provided by The Lewin Group, the beneficiary pays the first $250, plus 25% of the next $2,000 ($500), plus the full amount between $2,250 and the discounted total of $4,800 ($2,550), and a premium of $35/month ($420), for a total of $3,720. Medicare pays 75% of the amount between $250 and $2,250, or $1500. Since the Medicare portion is paid from tax funds, it is really an allocated portion of pooled consumer funds and, thus, a portion of the costs paid indirectly on behalf of the Medicare beneficiary. So the full amount paid by the beneficiary, directly and indirectly, is $5,220 ($3,720 plus $1,500).

Wait a minute. If Medicare didn’t even set up a drug program but merely negotiated a 20% discount, the cost would have been $4,800. Thus an extra $420 ($5,220 minus $4,800) is the penalty assessed because we prohibited Medicare from negotiating the same discount that the pharmacy benefit managers receive.

This example assumes only a negotiated drug discount for Medicare and nothing else. But suppose that Congress were to authorize a bona fide Medicare drug benefit. We would receive not only the discounts, but also the tremendous power of spreading the risk through an equitable system of funding the program. By expanding the program into a Medicare for All, we would further dilute the costs per beneficiary by including younger, healthier individuals who have little need for drugs now, but who want to have affordable access when they are older and in poorer health.

Privatize Medicare? No way! We need a single payer, national health insurance program. How about Medicare for All?

The Chaoulli Case: A Two-Tier Magna Carta?

By Gregory P. Marchildon
Healthcare Quarterly
Vol 8, No 4, 2005

Abstract:
There has been considerable speculation about the potential impact of the Supreme Court of Canada’s judgment in Chaoulli v. Quebec. Even if those who are most friendly – or most hostile – to Canadian medicare are exaggerating the impact of the decision, its impact will be large. While the decision does not strike down any existing single-payer medicare system in any province, including Quebec’s single-payer system, it is certainly capable of becoming the Magna Carta for two-tier medicare through future judicial interpretation and extension. In any event, it has already become the battering ram of choice for medicare’s most tenacious opponents.

In recent years, the critics of medicare have become more vocal about what they invariably describe as the monopoly of single-payer health care, often comparing Canadian healthcare to the command economy of the former Soviet Union. This perception is not only misleading – it is fundamentally wrong on a number of counts.

In the first place, Canadians are awash in choices when it comes to medicare. We have the freedom to choose our physician. Within our respective provinces and territories, we are free to choose our health institutions – one hospital over another, one clinic over another, depending on our personal preferences. And in contrast to the imagery of a single government bureaucracy perpetuated by the critics of medicare, almost all of our physicians are independent professionals working on fee schedules or contracts freely negotiated with provincial and territorial governments. Many of our clinics are private (not-for-profit as well as for-profit) and the majority of our hospitals are either private not-for-profit institutions or part of regional health authorities that have varying degrees of managerial autonomy from government. This contrasts sharply with the history of the National Health Service in Britain, in which hospitals and their employees all became part of a central government bureaucracy.

In the second place, medicare refers to a quite narrow range of health services – mainly hospital, diagnostic and physician services that are provided on a universal basis and without direct payment by the patient. These services constitute about 43 per cent of total healthcare expenditures in the country. Almost all other healthcare, including home care, nursing home care, prescription drugs, vision care and alternative medicines, are outside the medicare basket. In other words, the so-called monopoly covers less than one-half of Canadian healthcare and does not at all apply to mixed and private sectors of healthcare – sectors in which private insurance, user fees and direct payment are the rule rather than the exception. Moreover, the mixed and private sectors – comprising over 50 per cent of health expenditures – have contributed far more than the public sector to the high rate of growth in healthcare expenditures over the last decades.

Finally, we have always permitted two small exceptions to our single-payer medicare regimes – one private, the other public. On the private side, no one is prohibited from purchasing private health services as long as they pay out-of-pocket for those services from providers who have chosen to be non-participating members of a provincial medicare scheme. On the public side, workers’ compensation health benefits predate medicare and were legally excluded from the operation of the Canada Health Act and provincial medicare laws. Of the two, at least until the Chaoulli decision, the public tier of workers’ compensation has been more problematic in terms of its damage to the principle of universality by allowing a segment of the population preferential access to medicare services, occasionally through non-participating physicians and private facilities.

In contrast, the private exception based upon private payment never really developed in Canada for a number of complex reasons, particularly the refusal of provincial and territorial governments to subsidize private care or encourage physicians to work both sides of the public-private street at the same time. Although I know it is contentious to do so, I would add that the generally high quality of Canadian medicare has also prevented a large private market from developing. At any rate, the very few Canadians who have wanted such services have always been free to purchase them in the United States, where a ready market for privately purchased services has always existed because of the truncated nature of public health insurance in that country.

This brings us to the nub of the Supreme Court’s decision. Despite the lack of evidence, opponents of Canadian-style medicare, including Dr. Jacques Chaoulli, have long argued that the inability to purchase private insurance for medically necessary health services has been the key factor in preventing a viable second tier from emerging capable of competing with publicly administered medicare for customers (Coffey and Chaoulli 2001). They often point to examples such as Australia, where public and private hospital and physician services co-exist. Of course, they conveniently ignore the fact that the Australian government has had to provide a huge public subsidy in the form of a 30 per cent deduction for private insurance premiums to keep the private system in business, an experience that seems common in countries with such two-tier systems. In other words, public funds are often diverted to the wealthier members of society in order to prop up the private tier where it exists.

Proponents of medicare have long argued that to preserve the universality of a system, with access based solely on need, government needs to discourage the emergence of a separate “upper” tier of care based on ability to pay. Most governments in Canada have done so because they wanted to prevent major exceptions to the principle that access should be based on urgency of need. They have also done so to prevent a parallel private system from robbing the financial and human resources needed to run a top-notch public system. To protect their single-payer systems, different provinces have selected different and various means to discourage a second private tier. These means include: not allowing non-participating physicians to charge more than the medicare fee schedule; refunding patients only the medicare portion of fees paid to non-participating physicians; and in the case of six provinces (British Columbia, Alberta, Manitoba, Ontario, Quebec and Prince Edward Island) prohibiting private health insurance for medicare services.

In Chaoulli, the Supreme Court decided that Quebec’s prohibition on private health insurance is contrary to the Quebec Charter of Human Rights and Freedoms when an individual’s lengthy wait for medicare services seriously compromises the health of that individual. The court provided little guidance, however, in helping governments, health organizations and physicians know at what point a waiting time is too long. Moreover, little or no consideration was given to the fact that many provincial governments and health organizations, through initiatives such as the Western Canada Wait List Project and the Saskatchewan Surgical Care Network, have focused their efforts at understanding and shortening wait lists. Indeed, while the degree of success varies across and within provinces, there has been considerable progress in reducing waiting times in many parts of the country in the last couple of years.

Contrary to the majority view of the court, which seemed to swallow the monolithic, monopoly view of the world, medicare is actually a highly local system depending on the management and decisions of individual physicians, hospitals and regional health authorities. It is up to these organizations, under a publicly administered framework provided by the provincial government, to balance the many priorities, from urgent to elective care, and from sickness care to illness prevention and health promotion. We must ask ourselves whether the court’s concern with one waiting list problem in one city in one province is going to end up dictating the priorities of health organizations and governments throughout Canada, even further tipping the balance in favour of downstream illness care and away from prevention and promotion efforts that will keep us all healthier (and at less cost) in the long run.

So, what next?

In the face of this decision, those governments that support medicare should act now rather than waiting for the inevitable offensive driven by the powerful interests supporting the radical privatization of Canadian medicare. Individuals and groups within those provinces can strengthen the resolve of these governments by expressing their support for universal medicare, their opposition to allowing a private upper-tier of care, and initiating their own litigation to support the principles of medicare.

Those provinces that have prohibited private insurance should consider amendments that clarify the reasons for prohibition and the merits of a single-tier system of medicare. The legislative debates will force everyone to make their positions and assumptions clear and will provide an opportunity for medicare-friendly governments to set out the evidence supporting a single-tier system. Once enshrined in law, each government’s legislative intent will have to be taken into consideration in future court rulings.

The provinces that have not previously prohibited private insurance have at least two options open to them. They can re-examine the combination of measures they have used in place of an outright prohibition on private health insurance to protect the integrity of their single-payer systems, and the extent to which their circumstances may be similar to, or different from, the provinces with express prohibitions. They can then amend their own medicare laws to make clear their legislative intent to continue to preserve the integrity of their single-payer systems.

Although unlikely because of the inherent cautiousness of the advice given by health bureaucracies to their political masters, it would be interesting to see at least one provincial jurisdiction carefully draft a new law prohibiting private health insurance for the express purpose of having it tested in the courts, perhaps through a reference case. I am quite sure that it would be relatively easy in such a case to demonstrate the broader point that the policy measures relied upon by any government to protect medicare are better determined by governments accountable to the public through the democratic process than by the courts.

The federal government could also take some long overdue action to enforce the Canada Health Act. There is a reason that Montreal has the largest number of private MRI clinics in the country – a market has been created because of the extremely long waiting lists in the public sector and the willingness of participating physicians to encourage their more well-off patients to jump the medicare queue by getting a private MRI. If the federal government had forced this issue into the public domain years ago through a (temporary) reduction in its transfer payments, the Quebec government might have better ensured timeliness of care through the public system and not relied so surreptitiously on its private release valve. In more general terms, while it is up to individual provinces to decide on how best to administer (and protect) their respective single-payer systems, the federal government needs to continue to ensure that it is effectively discouraging major exceptions to the fundamental principles of public administration, universality, comprehensiveness, portability and accessibility.

Finally, I would like to offer some unsolicited advice to Premier Klein of Alberta, given his comments following the Chaoulli decision. If he truly believes that the founding principles of medicare are fundamentally flawed, then this court decision should finally give him the courage of his convictions. If he truly believes that Albertans endorse his vision, then he should immediately introduce a two-tier system. He can bypass the Canada Health Act by simply refusing federal health transfers in the future. If Saskatchewan was able to go it alone for years when it first introduced medicare, then surely oil-rich Alberta can now afford to go it alone. Albertans could then pay directly out-of-pocket or indirectly through private health insurance for a portion of their medicare services. Access for the majority would be based mainly on “ability to pay,” while access for the very poor (often defined as those on welfare) would be determined by a safety net type medicare program. Where the working poor fit into this picture is a little harder to determine but all Canadians outside Alberta would have a home-grown point of comparison on how the systems stack up against each other.

In the 1960s, this option was called Manningcare because Premier Ernest Manning was convinced of its merits compared to the universal medicare model. Personally, I would be confident that single-tier medicare would prove itself more efficient, effective and equitable in the comparison, just as it has done so relative to the American system. Whether a majority of Albertans would willingly go along with Premier Klein on this trip back to the past is highly questionable. Indeed, I suspect the majority of Albertans remains as opposed to a two-tier system as all other Canadians, a stubborn fact that explains the gap separating Klein’s bravado from his government’s timid actions on the ground.

We all know that the demand for healthcare services is potentially limitless. After protracted debates almost a half century ago, we decided that, at least for medicare services, rationing should be based upon urgency of need rather than ability to pay. Though the majority of Canadians continue to support that democratic decision and the founding principles of medicare, the Supreme Court through its Chaoulli Magna Carta is doing its best to force us back to the drawing board again.

About the Author
Gregory P. Marchildon, is Canada Research Chair and Professor Graduate School of Public Policy, University of Regina and Fellow, School of Policy Studies, Queen’s University. Email: greg.marchildon@uregina.ca.

References
Coffey, J. Edwin and J. Chaoulli. 2001. Universal Private Choice: Medicare Plus. Montreal: Montreal Economic Institute.

Will industry spur national health care?

Kalamazoo Gazette
Friday, October 28, 2005

Remember back in the 1960s when many politicians were having apoplexy over the prospect of Medicare?

Pure socialism, they ranted. It’ll break the bank!

Well, it hasn’t yet, although it has become obvious that Medicare, the health-insurance program for senior citizens, and Medicaid, a companion federal-state program to aid the destitute of all ages, have become hugely expensive and require streamlining and reform.

Now comes Gov. Jennifer Granholm with a suggestion for a national health plan. Is that a risky strategy for Granholm’s campaign for re-election next year?

Maybe not. This is Michigan, after all, and our auto industry is hurting. The big news recently is that Toyota will open a second auto manufacturing plant in Woodstock, Ontario, in 2008.

Toyota executives decided to forgo hundreds of millions of dollars in subsidies from several American states in favor of erecting their new plant less than 25 miles from its second Ontario plant and skilled workforce in Cambridge. It is expected that the new plant will bring well-paying jobs to 1,300 workers who would make 100,000 vehicles annually.

Often, in this space, we have called attention to the importance of a community having skilled workers. That’s why Michigan thrived for so many decades. The Japanese place a great importance on the abilities of the Canadian workers, much more so apparently than they did on those in southern states vying for the new plant.

The Toyota people also are aware of health-care costs. It was reported that because Canada has a taxpayer-supported national health insurance program that covers all citizens regardless of age, Toyota could save $4 to $5 an hour in benefits. Fortunately, the U.S. auto manufacturers and the labor unions have reached agreement on a new contract, which includes health-care provisions.

In America, excellent health care is available for seniors when they reach 65, affluent people who are covered by some type of private policy, or public health insurance for the very poor. But it’s different for tens of millions of our working poor. Many of them, honest and hard-working people, have lost everything they have to an expensive illness. In this land of plenty, that’s disgraceful.

All of these facts have not been lost on Granholm. The governor said Monday that some form of a national health care program — perhaps beginning with the use of public funds to take care of catastrophic costs for citizens of all ages — could be a starter.

Years ago, heads of big corporations and a lot of conservatives would have been aghast over such a plan. But, today, employee health-care insurance premiums are eating many industries alive.

Some otherwise unlikely allies could decide to receive Granholm’s notion with at least a modicum of enthusiasm.

A Republican Senate candidate supports single payer principles

Tarrant’s healthy idea
Brattleboro Reformer
October 26, 2005

IDX co-founder Richard Tarrant may be running for the Republican U.S. Senate nomination in 2006, but when it comes to health care, he has some ideas that are quite different from the same old things we hear from the Republican Party.

Tarrant’s company, which was recently purchased by General Electric for $1.2 billion, specializes in creating computer software for the health care industry. Through his work with IDX, Tarrant says he has a unique perspective on the health care issue.

“I’ve spent 35 years in it,” Tarrant told the Reformer during a meeting with the editorial staff on Monday. “I’ve seen a lot of different health care plans.”

Unlike many Republicans, Tarrant thinks single-payer health care isn’t a terrible thing. One reason why is that, at least for the elderly and the poor, the United States already has a form of it.

“Medicare is a bureaucracy, but it is one of the most efficient bureaucracies out there,” said Tarrant.

Because Medicare works in this regard, Tarrant would like to see it expanded so that the uninsured, small businesses and farmers could participate. It would be means-tested, with premiums based upon the ability to pay. Those who want to participate can do so, or stick with the current private insurance plan they might have.

Ultimately, Tarrant said, he would like Medicare, the elder health care plan, to merge with Medicaid, the health care plan for the very poor. This merger would make providing insurance more efficient.

“You have one plan for Medicare and a different plan in 50 different states for Medicaid,” said Tarrant. “And every state is having trouble paying for it. Medicaid can only be fixed on the federal level and I can see both programs eventually merging.”

Tarrant’s vision of a limited single-payer health insurance system functioning side-by-side with the current free market system is an intriguing idea. Although he didn’t discuss how it would be funded, his proposal certainly doesn’t reflect conservative orthodoxy.

His thoughts on health care may be a sign that Tarrant, who is better known for being one of the richest people in Vermont than for being a political thinker, may have some fresh ideas for next year’s Senate race.

http://www.reformer.com/Stories/0,1413,102~8854~3106021,00.html

Comment: Single payer advocates will be quick to point out that allowing a parallel private health insurance system defeats some of the efficiencies and equities of a single payer system. But what a shift in health policy views for a Republican!

It is anticipated that Independent Bernie Sanders, a very popular Vermont politician and outspoken single payer supporter, will be a candidate for the U.S. Senate. It may be that Tarrant’s statement on single payer is defensive posturing. But even if so, it is gratifying to see that a successful Republican businessman recognizes the validity and credibility of the single payer model.

Taking good care of WellPoint

WellPoint’s 3Q Profit More Than Doubles
By The Associated Press
The New York Times
October 26, 2005

WellPoint Inc. on Wednesday said earnings for the third quarter more than doubled as the company continued to reap the benefits of last year’s merger creating the largest health insurer in the U.S.

The company was formed last November when Indianapolis-based Anthem Inc. bought Thousand Oaks, Calif.-based WellPoint Health Networks Inc. and changed its name to WellPoint Inc.

(Third quarter) net income rose to $640.7 million, or $1.02 per share, from $242.1 million, or 85 cents per share.

Improvement at the company’s health-care segment was driven by strong membership growth, moderating medical costs in the current year, and synergies realized from the WellPoint-Anthem combination.

WellPoint is in the process of acquiring WellChoice, parent of Empire Blue Cross and Blue Shield. For 2006, WellPoint said it remains committed to its goal of achieving 15 percent growth in net income per share, not taking into account any effect from the WellChoice acquisition or from expensing stock options.

http://www.nytimes.com/aponline/business/AP-Earns-WellPoint.html

Comment: Why should we care about another ho-hum report on the profits of the nation’s largest health insurer? Well, theoretically, as health care consumers we are paying WellPoint and the other insurers for the services that they provide. So it’s fair to ask what benefits we are receiving from this very expensive, highly profitable enterprise. (Although I’ll use WellPoint in this discussion, the principles apply generally to the entire private insurance industry.)

Health care coverage in the United States is heavily dependent on employment-based plans. Our national and state policies are designed to protect and nurture this important sector of health care coverage. Policies have been established to be certain that this industry thrives, even if more and more burdens are being placed on employers and their employees. Without healthy insurers, our system of funding care would collapse (unless structural reform were enacted).

So who is covered under employer-sponsored plans? The nation’s workforce. These are comparatively young, healthy, gainfully employed individuals and their young, healthy families. Insurance is about pooling risk wherein the large numbers of healthy individuals pay into a pool to cover the high costs of the few with major health problems. But employment-based coverage segregates this very large sector of primarily healthy individuals and places them into a separate low-cost pool. So we have presented, on a silver platter, to the private insurance industry this highly lucrative sector, while relieving them of the need to cover most of us who do have significant health care needs.

What about private individual coverage? The story is much worse. The higher administrative costs of the individual market drive rates up to about 30% higher than comparable group coverage. Since these costs would make individual coverage unaffordable, the industry has responded by shifting costs from the insurer to the individual patient. Everyone is aware of the impact that this has had on individual bankruptcy, in spite of having insurance coverage. Even more alarming, the private insurers have been quite successful in excluding those with needs from individual coverage, either by exorbitant premiums or by underwriting exclusions. Once again, our policies have allowed the private insurance industry to skim off the healthy, leaving the sick behind.

Is the private insurance industry helping us to fund the care of those who do have significant needs? End of life care is shifted to the taxpayers through the Medicare program. Many of those with chronic disabilities are shifted to the Medicare and Medicaid programs. The uninsurable theoretically are shifted to high-risk pools, but they don’t exist in many states, and are non-accessible because of minuscule quotas and high premiums in most other states. Some low-income individuals with a high incidence of health care disparities are covered by the taxpayer-funded Medicaid program. And 46 million, mostly employed, low-income individuals, are not served by the private plans simply because they do not have the funds to support the insurance industry.

If the private insurers are avoiding risk pooling and are shifting costs to patients, then what are they selling us? Administrative services! Hundreds of billions of dollars in administrative services (though some of that is the wasteful administrative burden that they place on the health care delivery system).

WellPoint’s $641 million profit this quarter, annualized with the projected 15% increase means that WellPoint will have almost $3 billion in profits next year. But that number is dwarfed by the cost of the egregiously wasteful administrative services that they are foisting off on us.

19% of health care in the United States is funded through employer-sponsored plans. The other 81% is through public programs and private spending. Yet our legislators take far better care of the private insurers than they do us.

The insurers shun the sick, steal our money, and Congress and our state legislators want to keep them in charge!?

Entrepreneurial physicians and their specialty hospitals

Effects Of Physician-Owned Limited-Service Hospitals: Evidence From Arizona
By Jean M. Mitchell
Health Affairs
October 25, 2005

In recent years physician ownership of so-called limited-service hospitals has become commonplace in many states lacking certificate-of-need regulations. Empirical evidence documenting the effects of these facilities is sparse. This study compares practice patterns of physician-owners of limited-service cardiac hospitals and physician-nonowners who treat cardiac patients at competing full-service community hospitals. Analyses of six years of Arizona inpatient discharge data show that physician-owners treat higher volumes of profitable cardiac surgical diagnosis-related groups (DRGs), higher percentages of low-severity cases, and higher percentages of cases with generous insurance compared with physician-nonowners who treat cardiac patients in community hospitals.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.481v1

And…

The Rise Of The Entrepreneurial Physician
By Allen Dobson and Randall Haught
Health Affairs
October 25, 2005

…after reviewing the evidence, we note that physicians’ demands for more clinical autonomy and control over their incomes will not go away if specialty hospitals are “banned.” The emergence of specialty hospitals is a manifestation of a larger issue: the rise of the entrepreneurial physician. In response, community hospitals are partnering with physicians in numerous creative ways. Thus, the future outlets for physician demand for clinical and economic control may go beyond specialty hospitals to include variants of partnering between community hospitals and physicians, and perhaps gain-sharing arrangements or pay-for-performance systems as advocated by the CMS and MedPAC.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w5.494v1

Comment: There is no dispute that physicians who own specialty hospitals admit higher volumes of more profitable patients with better insurance coverage while avoiding less-profitable, complex cases. Although advocates of physician-owned specialty hospitals argue that market competition with community hospitals results in a higher quality product, there is no evidence for that.

The true reason for skimming off more profitable patients is very clear. The physician is using the single patient to provide fees for professional services and to provide investment income for a parallel entrepreneurial venture. Professional fees and investment income are each legitimate, independent sources of income. But does it matter that they arise from the same patient source?

Advocating for the best care for the patient has traditionally been rewarded with professional fees. Although fee-for-service can result in excessive services, and salaries can result in sloth, in general, payment for professional services serves the patient fairly well.

What about receiving entrepreneurial income in caring for the same patient? In order to create a maximum return on investment, decisions are made on a business model basis. That may or may not benefit the patient, but that doesn’t matter as long as it has a positive impact, or at least no negative impact, on the specialty-hospital market. It does not take much imagination to think of measures that would increase revenues (e.g, high-tech services of questionable value) and other measures that would decrease expenses (e.g., a cheaper but less-tested, implantable cardio-defibrillator). Since the patient-care algorithm and the business-decision algorithm frequently depart at various junctures, a physician could never escape the fact that a conflict exists, no matter how altruistic that physician is.

A greater concern for many of us is the financial burden that is placed on community hospitals when the profitable patients are diverted away. Community hospitals already have the burden of providing uncompensated care which, hopefully, can be offset by insured patients. But when they lose the better-insured patients, their safety-net function is threatened. Do we really want to support a few specialty hospitals as a tradeoff for accepting under-funded mediocrity for the rest our community hospital needs?

Dobson and Haught suggest that, since we are in the age of the entrepreneurial physician, community hospitals can compete by making “gain-sharing arrangements” with physicians. When we accept the fact that market competition must be the driving force in health care, it leads to perverse concepts such as the need to supplement professional income with entrepreneurial gain-sharing income. Kickbacks and fee-splitting are historical terms that have no significance in today’s entrepreneurial environment, but maybe we should give more thought as to why they were made illegal.

We need comprehensive structural reform in the way that we fund health care. We should pay physicians, and pay them well, simply for caring for their patients. A national health insurance program would do that, but it would also establish safeguards against perverse non-professional income that might be deleterious to the patient or to the health care system as a whole. And, besides, physicians would have complete freedom to invest elsewhere.

Diagnosis for America

By Jonathan Tasini
October 25, 2005
TomPaine.com

It is a measure of our lowered expectations, fueled by media spin, that people shrugged and seemed to think that it was inevitable that workers for General Motors were destined to have their health care coverage slashed. After all, some seemed to think, at a time when their company is teetering on the edge of oblivion, these “privileged” auto workers had “gold-plated” coverage that almost no other workers in America have.

But let’s be clear: The loss of benefits for GM workers was not inevitable. It happened as a result of many years of bipartisan political and economic decisions and the bipartisan lack of political courage to take on dumb ideology and corporate power.

In the minds of the elites, socking workers with a larger share of the costs of health care is just a natural part of the new economic order. As the Wall Street Journal editorial board said about the health care cost-cutting deal between GM and the United Auto Workers, “We hope it’s the beginning of wisdom about the global economy for the American labor movement.” Speaking about UAW president Ron Gettelfinger, Delphi CEO Steve Miller—who took his company into bankruptcy—said, “He’s going to have to help half a million of workers get used to the idea that globalization has taken away the ability to have someone who mows the lawn or sweeps the floor get $65 an hour.”

At least one thing is refreshing: It exposes as a fraud the liberal and conservative mantra about the wonders of the global economy. Democrats and Republicans alike—from Bill Clinton to George Bush, with a supporting cast of media and academic geniuses—have repeatedly told workers that the global economy will bring great benefits to America, after a period of “adjustment.” To their credit, Steve Miller and the Journal are more honest: The global economy is a tool to drive down living standards, starting with health care. Get with it, folks: Living large is so “old economy.”

So, the first obvious point to make is that employer-provided health care coverage has failed. Workers should never face the choice between sickness and financial ruin simply because the company they work for is going under, poorly managed or because they change jobs. More important, this has become, as I pointed out some months ago, a matter of economic competitiveness for corporations based in the United States: The health care system is dragging down profits.

The second point, then, is that health insurance can never be left to those whose sole motivation is profit. The last time health care was debated, the Clinton administration lost its nerve—or, perhaps, never had any other intention to pursue a system other than one that was destined to perpetuate the existing ideological flaws. “Hillarycare” was a disaster for the public not because the mismanaged process produced an overly complex system. Rather, the Clintons made a conscious decision to leave health care in the hands of the private insurers—which allowed the HMO industry to grow, if you’ll pardon the expression, like a malignant tumor.

If we had different philosophy, GM workers’ health care would never change. As Ida Hellander, executive director of Physicians for a National Health Program (PNHP), puts it, “Political will is infinitely harder to muster, especially when Congress is owned by the drug and insurance companies.” PNHP has a very straightforward set of four principles guiding its universal health care proposal, which I think, if properly understood by the public, would send millions of people to the streets demanding immediate change:

* Access to comprehensive health care is a human right. It is the responsibility of society, through its government, to assure this right. Coverage should not be tied to employment. Private insurance firms’ past record disqualifies them from a central role in managing health care.

* The right to choose and change one’s physician is fundamental to patient autonomy. Patients should be free to seek care from any licensed health care professional.

* Pursuit of corporate profit and personal fortune have no place in caregiving and they create enormous waste. The U.S. already spends enough to provide comprehensive health care to all Americans with no increase in total costs. However, the vast health care resources now squandered on bureaucracy (mostly due to efforts to divert costs to other payers or onto patients themselves), profits, marketing and useless or even harmful medical interventions must be shifted to needed care.

* In a democracy, the public should set overall health policies. Personal medical decisions must be made by patients with their caregivers, not by corporate or government bureaucrats.

The economics of a single-payer, universal health care system are unassailable. It would save $300 billion in administration costs. It would be financed partly by the 60 percent of taxes that already go into the health care system via Medicaid, Medicare and payments for public employee coverage. The rest of the financing, over the long term, would be easily done with modest tax increases (by a 7 percent payroll tax and a 2 percent progressive income tax) —and result in better health care for people for less money than people shell out in ever-rising deductibles. With one bold stroke, a single-payer system would do more to help the bottom line of companies than any tax break or so-called “free trade” agreement.

The troubling reality to the arguments I’ve made is that they are not particularly original: The moral and economic need for a universal health care system has been well-known for a very long time. The only question now is: How many companies will have to go belly up and how many more millions of workers will face bankruptcy and illness because we allow ideology—the deification of the so-called free market—to triumph over common sense?

Jonathan Tasini is president of the Economic Future Group and writes his “Working In America” columns for TomPaine.com on an occasional basis. His blog Working Life chronicles the labor movement and other issues affecting American workers.

www.tompaine.com/articles/20051025/diagnosis_for_america.php

Wal-Mart creates pseudo-insurance

Wal-Mart to Expand Health Plan for Workers
By Michael Barbaro
The New York Times
October 24, 2005

Wal-Mart, which has long been criticized for the benefits it offers to its workers, is introducing a cheaper health insurance plan, with monthly premiums as low as $11 (available in a handful of areas), that the company hopes will greatly increase the number of its employees who can afford coverage.

Jumping into a new area, Wal-Mart is also offering health savings accounts, which the federal government introduced last year. Few employers offer them.

The new benefits, which Wal-Mart calls the Value Plan, follow years of complaints that at Wal-Mart, the nation’s largest employer, health insurance is out of reach for many of its 1.2 million workers in the United States, forcing thousands of them to turn to state-sponsored programs or forgo health coverage altogether.

Health insurance specialists generally praised the new plan, saying its lower premiums were likely to attract more employees and thereby reduce the ranks of the uninsured. They also noted, however, that the plan’s $1,000 deductible would be high for Wal-Mart workers…

But the plan is unlikely to cover a complicated illness or expensive hospital stay during the first year, when there is a $25,000 insurance cap. (The cap is lifted for the second year.) Out-of-pocket payments range from $300 for prescriptions to $1,000 for hospital stays.

The company’s health savings accounts will combine low monthly premiums with a requirement that individuals cover a substantial part of their own health care costs.

Several health insurance specialists questioned whether the company, which is working to burnish its public image, was trying to quickly increase the number of workers who use its health insurance at the expense of the coverage’s quality.

http://www.nytimes.com/2005/10/24/business/24mart.html

Comment: Although we do not yet have the details of Wal-Mart’s Value Plan, enough information has been released to raise very serious questions about whether this coverage provides financial security for those with medical needs.

Although the premiums will be very low, they likely would not be affordable for an individual that has no discretionary income, which is the case for most Wal-Mart employees.

Health savings accounts are advantageous for higher-income individuals since they are subsidized by the taxpayer. But most Wal-Mart employees would not receive any tax subsidy for these accounts because their incomes are too low to pay income taxes. Why would they place personal funds in an account that provides no advantage but that would be penalized if they used their funds for other essential needs, such as food or rent? Besides, they simply do not have the extra income to fund a savings account even if they wanted to.

Although three visits are covered before the deductible kicks in (to encourage preventive services), a $1000 doughnut hole so early in accessing the benefits creates a chasm which most would not be able to ford.

And a major catastrophic event would leave many individuals exposed since the costs typically would exceed the $25,000 cap.

We already know that under-insurance perpetuates many of the problems experienced by the uninsured, such as impaired access due to lack of affordability, with resultant impaired health outcomes. But this degree of under-insurance in an employee population with very low incomes creates yet a new category of insurance: pseudo-insurance. It looks like insurance, but it isn’t.

UAW statement on tentative agreement with GM

UAW statement on tentative agreement with GM
UAW
October 20, 2005

UAW President Ron Gettelfinger and Vice President Richard Shoemaker:

“The tentative agreement asks every UAW-GM member, active and retired, to make sacrifices so that everyone can continue to receive excellent health care coverage today and in the future.

“We believe the tentative agreement is an innovative and equitable way to address the health care cost issue at GM.

“However, as we have said many times before, no one union and no one company can solve America’s health care crisis. America is the only advanced nation in the world without some form of national health care – and U.S. businesses and America’s working families are paying a high price for this nation’s uncompetitive public policies. Indeed, GM, Ford and DaimlerChrysler are benefiting from Canada’s national health care system.

“The UAW has long advocated single-payer national health insurance as the most cost-effective and fairest way to fix America’s health care crisis.
Today, we are more determined than ever to make single-payer national health insurance a reality.”

http://www.uaw.org/news/newsarticle.cfm?ArtId=359

Comment: So are we.

Significance of the GM/UAW deal

GM DEAL: Cries of pain mix with sighs of relief
By Michael Ellis
Detroit Free Press
October 21, 2005

The UAW unveiled details of the much-anticipated health plan Thursday. Under it, retirees would have to pay monthly premiums and annual deductibles.

Active hourly workers at GM would defer $1 an hour from pay increases they were due in 2006, or about $2,000, into a fund to pay for their health care. By the end of 2006, that deferral would increase by 2 cents an hour every quarter.

With the concessions, GM hourly retirees would pay a maximum of $752 per family each year for health care, or $370 annually for an individual, plus co-payments for prescription drugs.

The package would create a defined contribution plan to help pay for health care costs. GM plans to contribute $3 billion — with $1-billion payments in 2006, 2007 and 2011. Wage deferrals by hourly workers would help fund the plan, which the UAW would administer.

“It’s a concrete demonstration of the health care crisis in our country,” said Richard Block, a labor professor at Michigan State University. “Everybody’s getting poorer because of health care.”

http://www.freep.com/money/autonews/gm21e_20051021.htm

Comment: This is the end of an era. The auto industry is the largest and the last of private employers to have provided complete health care coverage as a benefit of employment. They have now introduced cost sharing and defined contribution funding which transfers to the employee some of the responsibility for funding care.

The changes are quite modest compared to what has already happened to employer-sponsored coverage in other industries and services. Larger deductibles, the shift to coinsurance from co-payments, defined contributions in segregated accounts, innovative reductions in benefits, and other measures have all served to shift more and more of the costs from the employer to the individual.

All of this is in the name of making health coverage more affordable to the employer. The obvious trade-off is that it makes health care less affordable to the individual. This shift addresses the employers’ concerns over escalating health care costs, but in shifting those costs to the employees, it does absolutely nothing to address the fundamental underlying problem. Health care costs continue to skyrocket. Shifting those costs to the hapless employee can have only one outcome: the employee and his or her family members will be empowered to not receive the health care that they can no longer afford.

Although it seems that this is simply the end of the era of 100% coverage, we are really witnessing a process that will end the role of the employer as the guarantor of health care services. As the cost of coverage continues to rise, employers will further reduce or even eliminate benefits. The financial burden shifted to individual employees will be truly excessive and the entire employment-based system will collapse.

Anticipating this, many policymakers are encouraging a shift to the individual insurance market, a market that is characterized by underwriting requirements, greater administrative costs, Spartan coverage, higher cost sharing, and a relaxed regulatory environment. Individual coverage, as a universal or near-universal system, will never fly because it will be so heavily weighted down with financial burdens that it cannot possibly get off the ground. The reason that our fragmented system of individual and group plans is doomed is that they are unable to address the overriding issue: escalating health care costs.

To control costs, a system must be in place that is targeted to cost excesses. The tremendous administrative waste can be dramatically reduced by using a single, efficient administrative payer. Wasteful high-tech excesses can be reduced by ensuring appropriate capacity through planning of capital improvements, budgeted by a single payer. Greater efficiency can be established by strengthening our primary care infrastructure through incentives established by a single payer. Excessive pricing can be reduced through negotiation with a single payer.

Although the employment-based system is self-destructing, and the individual market will never get off the ground, the good news is that we can achieve affordable access to comprehensive care for everyone. As the current system continues to implode, the logic of a single payer becomes ever more apparent.

Group urges universal health care system

Payroll, income taxes would cover costs
By David Wenner
The Patriot-News (Harrisburg, PA)
Tuesday, October 18, 2005

A grassroots organization yesterday proposed tearing down the health insurance system in Pennsylvania and building a new one that would cover everyone.

The proposal calls for universal coverage through a single-payer system that would pay 100 percent of medical and prescription drug costs while involving no direct charges to patients.

It would cost an estimated $43 billion annually and be funded through a 10 percent tax on business payrolls and a three percent tax on personal income.

Supporters says the winners would be state residents and businesses who can’t afford the high cost of health care, and the losers would be drug companies and health insurers.

Drug companies would lose because the system would obtain bulk discounts on drugs, and insurers would lose because they would no longer be needed, said Steve Larchuk, a Pittsburgh-area lawyer and a leader of Pennsylvania Healthcare Solutions Coalition, which has proposed the system.

The insurance industry, including Pennsylvania’s four Blue Cross-Blue Shield plans, will fight to preserve the existing system, Larchuk said.

“I expect the Blues will fight to the death to stop any kind of health care reform. But that’s a battle we have to fight sooner or later; and if we’re unwilling to fight that battle, we might as well hand the keys to the Capitol to the Blues right now,” he said.

Charlie Crystle, a Lancaster business owner and member of the coalition board, predicted businesses will support the single-payer system because the proposed payroll tax would be less than they now pay to provide health insurance for workers.

Larchuk said organizers have been working at the grassroots level for about a year, and avoiding involvement of politicians because the issue is so political.

The idea of universal, single-payer health insurance isn’t new.

Proposals exist in several states, Larchuk said.

Yesterday, supporters began visiting state legislators and passing out a draft of a bill to create the single-payer system.

Amy Kelchner, a spokeswoman for Gov. Ed Rendell’s Office of Health Care Reform, said Rendell is interested in any proposal to provide universal health insurance.

The administration recently received a federal grant it will use to explore universal coverage, she said.

The Pennsylvania Medical Society, the lobbying group for doctors, received the proposal yesterday and wasn’t ready to comment, spokesman Chuck Moran said.

State Sen. Pat Vance, R-Cumberland, a leader on health care issues in Pennsylvania, also said she had just heard of the proposal and hadn’t formed an opinion.

Cliff Shannon, president of SMC Business Councils and a leading advocate for health insurance reform in Pennsylvania, said no reform will succeed unless it includes a way to limit the cost of health care.

An uncapped, mandatory tax on businesses would have “no chance” of acceptance from businesses, he said.

Mike Fiachetti, a senior vice president for Highmark Blue Shield, said that with the high cost of health care, it’s no surprise that people are proposing a single-payer system.

But he said there’s no “silver bullet” solution for out-of-control health care costs.

“This all sounds good on paper, but there are so many things missing, it’s hard to even comment,” he said.

DAVID WENNER: 255-8172 or dwenner@patriot-news.com

Drug Business Prescribes a Novel Cure for Its Ills

by Lloyd Grove
New York Daily News
October 17, 2005

Who knew that the multibillion-dollar U.S. pharmaceutical industry was so keen on publishing pulp fiction?

In a tale worthy of a zany Washington satire – except for the lamentable fact that it’s true – the rich and powerful pharmaceutical lobby secretly commissioned a thriller novel whose aim was to scare the living daylights out of folks who might want to buy cheap drugs from Canada.

When the project fell through in July, I’m told the drug lobby offered $100,000 to the co-authors and publisher in a vain effort to sweep it under the rug.

Talk about thinking outside the box!

“This is the most outrageous example of deception and duplicity on the part of a Washington lobby in the history of the country,” said Capitol Hill denizen Jeff Weaver, chief of staff to Rep. Bernie Sanders (I-Vt.), a diehard foe of the pharmaceutical industry.

Drug-lobby mouthpiece Ken Johnson, executive vice president of the Pharmaceutical Research and Manufacturers of America, acknowledged the hare-brained scheme but shifted blame.

“We did not commission a book,” Johnson argued. “The idea was brought to us by an outside consultant. We explored it, provided some background information … but in the final analysis, decided it wasn’t the right thing for us to do.”

I’m told that Mark Barondess, a well-known divorce lawyer in Washington, D.C., was the so-called outside consultant and approached L.A.-based Phoenix Books with the novel idea.

Phoenix honcho Michael Viner, who happens to be Barondess’ publisher, struck a six-figure deal. I’m told PhRMA made at least one payment to Phoenix.

Viner declined comment, and Barondess didn’t respond to my detailed message.

Work began in April, after Viner hired veteran ghostwriter Julie Chrystyn. Her story concerned a Croatian terrorist cell that uses Canadian Web sites to murder millions of unwitting Americans looking for cut-rate pharmaceuticals.

PhRMA has vigorously fought all efforts to legalize the purchase of cheap drugs from Canada. Even though the lobby has found some success, the underground business still takes an estimated $1 billion in annual profits from American drug behemoths.

Chrystyn titled her thriller-in-progress “The Spivak Conspiracy,” an homage to her friend Kenin Spivak, an L.A. telecomm entrepreneur and onetime Hollywood exec.

Spivak said he became Chrystyn’s co-writer after she delivered the first 50 pages, and PhRMA made several editorial suggestions.

“They said they wanted it somewhat dumbed down for women, with a lot more fluff in it, and more about the wife of the head Croatian terrorist, who is a former Miss Mexico,” Spivak told me.

Apparently, women are among the most loyal buyers of Canadian drugs.

“They also wanted to change the motivating factor of the terrorists to greed, because they didn’t want it to be politics,” Spivak said. “They wanted lots of people to die.”

Spivak told me that since PhRMA pulled out – and he and his colleagues rejected the lobby’s offer of $100,000 to kill the project – he and Chrystyn have finished a revised version, “The Karasik Conspiracy,” due early next year.