PNHP

Genomics, bioinformatics, and single payer

Genomics, bioinformatics, and single payer

Decoding Health Insurance
By Robin Cook
The New York Times
May 22, 2005

In this dawning era of genomic medicine, the result may be that the concept of private health insurance, which is based on actuarially pooling risk within specified, fragmented groups, will become obsolete since risk cannot be pooled if it can be determined for individual policyholders.

Genetically determined predilection for disease will become the modern equivalent of the “pre-existing condition” that private insurers have stringently avoided.

As a doctor I have always been against health insurance except for catastrophic care and for the very poor. It has been my experience that the doctor-patient relationship is the most personal and rewarding for both the patient and the doctor when a clear, direct fiduciary relationship exists. In such a circumstance, both individuals value the encounter more, which invariably leads to more time, more attention to potentially important details, and a higher level of patient compliance and satisfaction – all of which invariably result in a better outcome.

But with the end of pooling risk within defined groups, there is only one solution to the problem of paying for health care in the United States: to pool risk for the entire nation. (Under the rubric of health care I mean a comprehensive package that includes preventive care, acute care and catastrophic care.) Although I never thought I’d advocate a government-sponsored, obviously non-profit, tax-supported, universal access, single-payer plan, I’ve changed my mind: the sooner we move to such a system, the better off we will be. Only with universal health care will we be able to pool risk for the entire country and share what nature has dealt us; only then will there be no motivation for anyone or any organization to ferret out an individual’s confidential, genetic makeup.

There are plenty of compelling arguments for a national, single-payer, universal access plan – like every developed industrialized country has one. But those arguments have so far seemed insufficient. And none of them is nearly as cogent and persuasive as the growing impact of genomics and bioinformatics. Of course, far too many wealthy stakeholders in the current system (thanks to 15 percent of our gross domestic product being thrown at health care) are eager to lobby members of Congress to keep things as they are. The basic challenge is to blast the public and their elected representatives out of their shared apathy toward what the decipherment of the human genome has brought.

Robin Cook is a medical doctor and the author, most recently, of the novel “Marker.”

http://www.nytimes.com/2005/05/22/opinion/22cook.html?pagewanted=all

Comment: Every time that reason is introduced into the national dialogue on reform, the arguments for a single payer system become ever more compelling.

Moderate and populist Republicans favor tax-supported,government health insurance

The Pew Research Center
Survey Report
Beyond Red vs. Blue
May 10, 2005

Health Insurance

Solid majorities of every group, with the sole exception of Enterprisers, favor a government guarantee of health insurance for all Americans, even if it means raising taxes. Across the electorate, support for guaranteed health insurance ranges from 55% among Upbeats and 59% among Social Conservatives to 90% among Liberals. By contrast, Enterprisers strongly oppose guaranteed health insurance for all, if it means higher taxes (76% oppose, 23% favor).

Percent favoring government health insurance for all, even if taxes increase:

65% of the total

23% of enterprisers

59% of social conservatives

63% of pro-government conservatives

55% of upbeats

64% of disaffecteds

73% of conservative Democrats

65% of disadvantaged Democrats

90% of liberals

For profiles of the typology groups:
http://people-press.org/reports/display.php3?PageID=949

For navigating the full report:
http://people-press.org/reports/display.php3?ReportID=242

Comment: Only the enterprisers (“staunch conservatives”) are opposed to tax-supported, government health insurance. The remarkable finding is that 59% of social conservatives (“moderate Republicans”) and 63% of pro-government conservatives (“populist Republicans”) do favor tax-supported government health insurance. Now if we can only get them to communicate that to their legislators.

Waiting for C.E.O.'s to Go 'Nuclear'

Waiting for C.E.O.’s to Go ‘Nuclear’
Op-ed
By Matt Miller
New York Times
May 18, 2005

The consuming Senate slugfest over judges (vital as they are) proves how Washington remains determined to fiddle while our biggest problem burns: a broken health care system that threatens working families and national competitiveness.

President Bush – who, with 51 percent of the vote, has set 100 percent of the agenda – has taken a pass. And the terms of the debate remain surreal. After all, Margaret Thatcher would have been driven from office if she’d proposed anything as radically conservative as Bill Clinton’s health plan, which would have left millions uncovered and had private doctors deliver the care.

Is there hope? Maybe. But only if America’s chief executives exercise their “nuclear option.”

Here’s the logic. Washington will offer zero leadership on health reform until 2009. The only way we’ll get serious then is if the campaign in 2008 centers on health. The only way that will happen is if groundwork is laid in advance. And the only way this groundwork will get traction is if America’s C.E.O.’s make it their mission.

Various groups (including one I’m paid to advise) have tried, without much luck, to energize this debate. C.E.O.’s are the one group with the incentive and the clout to take it on.

So what should the chief executives do? Even if we don’t have presidential leadership now, we desperately need the “presidential perspective.” By this I mean a view of our challenges that doesn’t reflect the narrow agenda of business or labor, or the medical-industrial complex. Instead, we need a “big picture” framework, a way to engage the press and the public in the right strategic goals.

Here’s my version of the script: A dozen marquee C.E.O.’s would convene a “Manhattan Project”-style effort on the future of health care. They’d propose a new goal: instead of health costs rising from today’s 15 percent of G.D.P. to 20 percent by around 2020, as is now projected, the nation should shave two to three percentage points of G.D.P. (or more) off projected growth in ways that improve quality, even as we extend coverage to the 45 million uninsured.

Our chief executives would explain that this is doable because today’s system costs too much and delivers too little.

(Quick review: We spend 15 percent of G.D.P. on health. Other rich nations spend 10 percent or less, but they manage to insure everyone – and have equal or better public health outcomes. And we have huge variations in practice patterns and medical spending that bear no relation to quality. Bottom line: radical inefficiency.)

Our C.E.O.’s would add that a new health strategy would get excess costs off businesses’ backs – costs that competitors don’t face in countries where governments pick up the tab. It would re-engineer the delivery of care so governments would have cash left for other purposes. And it would cope with the political reality that every dollar of health care “waste” is somebody’s dollar of income.

The group would issue a report in late 2007 with a full-blown agenda for the next president. Done right, the “Jones” Report (aspiring C.E.O. statesmen or stateswomen, picture your name here!) would become the touchstone for all health care talk in the campaign.

Now my rules for participation: First, only chief executives prepared to invest real time need apply. This shouldn’t be a bar; health costs now loom so large that C.E.O.’s are destined to focus on the problem. They can’t fix it alone, so they may as well fix it for everyone. (As a lure, we might enact a 100 percent short-term capital gains tax on their stocks during the life of the group to banish speculators and free the chiefs to think long-term.)

Next, eligible C.E.O.’s have to grasp that most rhetoric in the health debate – as exemplified by the Thatcher example above – is rubbish. Republican C.E.O.’s who think “big government” is always the problem may be at special psychic risk.

Critics may shout: Why should we want some lavishly paid bosses to take the lead? Well, for starters, as the Clinton debacle proved, if business doesn’t buy in, nothing that matters here can change. But beyond this, spiraling health costs have aligned corporate interests with workers’ for the first time in ages. My hunch is that inside many car and computer and bank and energy moguls, tomorrow’s political heroes are dying to get out.

Ordinarily a bold call for a commission is a way to punt, but given today’s leadership vacuum, it’s a way to start. I’m not saying that this will end with C.E.O.’s marching on Washington to demand “Margaret Thatcher-style universal health coverage.” But I wouldn’t rule it out either.

E-mail: mattmiller@nytimes.com; Matt Miller is the author of “The 2 Percent Solution: Fixing America’s Problems in Ways Liberals and Conservatives Can Love.” Maureen Dowd is on book leave.

Waiting for C.E.O.’s to Go ‘Nuclear’

Waiting for C.E.O.’s to Go ‘Nuclear’
Op-ed
By Matt Miller
New York Times
May 18, 2005

The consuming Senate slugfest over judges (vital as they are) proves how Washington remains determined to fiddle while our biggest problem burns: a broken health care system that threatens working families and national competitiveness.

President Bush – who, with 51 percent of the vote, has set 100 percent of the agenda – has taken a pass. And the terms of the debate remain surreal. After all, Margaret Thatcher would have been driven from office if she’d proposed anything as radically conservative as Bill Clinton’s health plan, which would have left millions uncovered and had private doctors deliver the care.

Is there hope? Maybe. But only if America’s chief executives exercise their “nuclear option.”

Here’s the logic. Washington will offer zero leadership on health reform until 2009. The only way we’ll get serious then is if the campaign in 2008 centers on health. The only way that will happen is if groundwork is laid in advance. And the only way this groundwork will get traction is if America’s C.E.O.’s make it their mission.

Various groups (including one I’m paid to advise) have tried, without much luck, to energize this debate. C.E.O.’s are the one group with the incentive and the clout to take it on.

So what should the chief executives do? Even if we don’t have presidential leadership now, we desperately need the “presidential perspective.” By this I mean a view of our challenges that doesn’t reflect the narrow agenda of business or labor, or the medical-industrial complex. Instead, we need a “big picture” framework, a way to engage the press and the public in the right strategic goals.

Here’s my version of the script: A dozen marquee C.E.O.’s would convene a “Manhattan Project”-style effort on the future of health care. They’d propose a new goal: instead of health costs rising from today’s 15 percent of G.D.P. to 20 percent by around 2020, as is now projected, the nation should shave two to three percentage points of G.D.P. (or more) off projected growth in ways that improve quality, even as we extend coverage to the 45 million uninsured.

Our chief executives would explain that this is doable because today’s system costs too much and delivers too little.

(Quick review: We spend 15 percent of G.D.P. on health. Other rich nations spend 10 percent or less, but they manage to insure everyone – and have equal or better public health outcomes. And we have huge variations in practice patterns and medical spending that bear no relation to quality. Bottom line: radical inefficiency.)

Our C.E.O.’s would add that a new health strategy would get excess costs off businesses’ backs – costs that competitors don’t face in countries where governments pick up the tab. It would re-engineer the delivery of care so governments would have cash left for other purposes. And it would cope with the political reality that every dollar of health care “waste” is somebody’s dollar of income.

The group would issue a report in late 2007 with a full-blown agenda for the next president. Done right, the “Jones” Report (aspiring C.E.O. statesmen or stateswomen, picture your name here!) would become the touchstone for all health care talk in the campaign.

Now my rules for participation: First, only chief executives prepared to invest real time need apply. This shouldn’t be a bar; health costs now loom so large that C.E.O.’s are destined to focus on the problem. They can’t fix it alone, so they may as well fix it for everyone. (As a lure, we might enact a 100 percent short-term capital gains tax on their stocks during the life of the group to banish speculators and free the chiefs to think long-term.)

Next, eligible C.E.O.’s have to grasp that most rhetoric in the health debate – as exemplified by the Thatcher example above – is rubbish. Republican C.E.O.’s who think “big government” is always the problem may be at special psychic risk.

Critics may shout: Why should we want some lavishly paid bosses to take the lead? Well, for starters, as the Clinton debacle proved, if business doesn’t buy in, nothing that matters here can change. But beyond this, spiraling health costs have aligned corporate interests with workers’ for the first time in ages. My hunch is that inside many car and computer and bank and energy moguls, tomorrow’s political heroes are dying to get out.

Ordinarily a bold call for a commission is a way to punt, but given today’s leadership vacuum, it’s a way to start. I’m not saying that this will end with C.E.O.’s marching on Washington to demand “Margaret Thatcher-style universal health coverage.” But I wouldn’t rule it out either.

E-mail: mattmiller@nytimes.com; Matt Miller is the author of “The 2 Percent Solution: Fixing America’s Problems in Ways Liberals and Conservatives Can Love.” Maureen Dowd is on book leave.

Quentin Young on health care costs for business

A National Plan
Health costs making big business ill
By Quentin Young, a Chicago physician and coordinator of Physicians for a National Health Program
Chicago Tribune
May 15, 2005

On April 19, General Motors Corp. blamed its dismal first-quarter results (a $1.1 billion loss) on its $5.6 billion annual health-care tab. On top of that, the company carries $63 billion in unfunded health-benefit costs. The future certainly looks bleak.

Clearly a disaster is looming not only for GM and its workforce, but also for the entire American economy. America’s other largest corporations also face skyrocketing health-care costs; General Electric Co., Boeing Co., Lucent Technologies Inc., IBM Corp., Verizon Communications Inc., SBC Communications Inc. and Ford Motor Co. have a combined $150 billion in future health-benefit obligations. Their future looks bleak too.

Ominously, non-competitive American products are sending our jobs abroad.

From candy to autos, Canadians can produce goods more cheaply because of their markedly lower health-benefits costs. For example, in Canada a Ford costs $1,400 less to make than it does to produce in Michigan. Lifesavers shaved $4 per hour off its labor costs by boarding up its hometown factory in Holland, Mich., and heading for Canada.

Alert pundits are, at long last, calling U.S. business to account.

They are pointing out what has been obvious to all industrialized democratic nations around the world for some time now: Employer-based health-care benefits are a bottomless pit. Seventeen American steel manufacturers have declared bankruptcy and terminated their retirees’ health benefits.

Our nation recently learned that half of all personal bankruptcies are due to unpaid medical bills and illness, affecting 2 million people each year. Corporate bankruptcy of huge proportion looms due to our failure to deal rationally with health-care financing.

There goes America’s vaunted economic advantage.

The obvious remedy, single-payer national health insurance, would end the link between employment and health insurance, while recovering much of the one third of health spending now squandered on “administrative cost,” at least $400 billion in 2004.

These funds would enable our nation to cover everyone with no increase in health spending. National health insurance can cut waste and prudently control soaring costs, something business has learned it cannot do on its own.

Paradoxically, it is America’s traditionally conservative physicians who are learning that the future fortunes of the medical profession, like the success of American business, hinge on reform of health-care finances.

Hence physicians, in increasing numbers, endorse single-payer national health insurance. Single-payer would address seriously the major deficiencies in our system: 45 million people without insurance, prohibitively priced pharmaceuticals, miserable mental-health benefits and the absence of a long-term care strategy for our aging population.

Single-payer would give business a level playing field with international competitors in the global economy by relieving them once and for all of the burden of crushing health benefit costs.

This healthy prescription can cure our chaotic health-care system and, in the process, foster a strong economy.

http://www.chicagotribune.com/news/opinion/chi-0505140245may15,0,6367117.story?coll=chi-newsopinionperspective-hed

Comment: The single payer model is the most comprehensive and least expensive of all models of reform. It seems only logical that business leaders, supporting cost containment, and social progressives, supporting comprehensiveness and universality, would want to sit down and discuss this.

Health costs making big business ill

By Quentin Young
A Chicago physician and coordinator of Physicians for a National Health Program
Published May 15, 2005

On April 19, General Motors Corp. blamed its dismal first-quarter results (a $1.1 billion loss) on its $5.6 billion annual health-care tab. On top of that, the company carries $63 billion in unfunded health-benefit costs. The future certainly looks bleak.

Clearly a disaster is looming not only for GM and its workforce, but also for the entire American economy. America’s other largest corporations also face skyrocketing health-care costs; General Electric Co., Boeing Co., Lucent Technologies Inc., IBM Corp., Verizon Communications Inc., SBC Communications Inc. and Ford Motor Co. have a combined $150 billion in future health-benefit obligations. Their future looks bleak too.

Ominously, non-competitive American products are sending our jobs abroad.

From candy to autos, Canadians can produce goods more cheaply because of their markedly lower health-benefits costs. For example, in Canada a Ford costs $1,400 less to make than it does to produce in Michigan. Lifesavers shaved $4 per hour off its labor costs by boarding up its hometown factory in Holland, Mich., and heading for Canada.

Alert pundits are, at long last, calling U.S. business to account.

They are pointing out what has been obvious to all industrialized democratic nations around the world for some time now: Employer-based health-care benefits are a bottomless pit. Seventeen American steel manufacturers have declared bankruptcy and terminated their retirees’ health benefits.

Our nation recently learned that half of all personal bankruptcies are due to unpaid medical bills and illness, affecting 2 million people each year. Corporate bankruptcy of huge proportion looms due to our failure to deal rationally with health-care financing.

There goes America’s vaunted economic advantage.

The obvious remedy, single-payer national health insurance, would end the link between employment and health insurance, while recovering much of the one third of health spending now squandered on “administrative cost,” at least $400 billion in 2004.

These funds would enable our nation to cover everyone with no increase in health spending. National health insurance can cut waste and prudently control soaring costs, something business has learned it cannot do on its own.

Paradoxically, it is America’s traditionally conservative physicians who are learning that the future fortunes of the medical profession, like the success of American business, hinge on reform of health-care finances.

Hence physicians, in increasing numbers, endorse single-payer national health insurance. Single-payer would address seriously the major deficiencies in our system: 45 million people without insurance, prohibitively priced pharmaceuticals, miserable mental-health benefits and the absence of a long-term care strategy for our aging population.

Single-payer would give business a level playing field with international competitors in the global economy by relieving them once and for all of the burden of crushing health benefit costs.

This healthy prescription can cure our chaotic health-care system and, in the process, foster a strong economy.

Coverage of vaccines by private plans

Coverage Of Vaccines In Private Health Plans: What Does The Public Prefer?
By Matthew M. Davis and Kathryn Fant
Health Affairs
May/June 2005

Immunization rates for the primary series of vaccines among children and for the widely recommended influenza and pneumococcus vaccines among adults fall short of targets set in Healthy People 2010. Lack of insurance and the resulting economic barriers have been blamed in part for these low immunization rates. In addition, immunization officials and policy experts have recently turned their attention to the problem of underinsurance for vaccines. The most recent estimates indicate that as many as 15 percent of children and more than 30 percent of all adults are enrolled in health plans that do not pay for recommended vaccines.

http://content.healthaffairs.org/cgi/content/full/24/3/770

Comment: It would be unimaginable that vaccines would ever be excluded from a universal public health insurance program. Yet many private insurers fail to provide such coverage.

Why do we continue to hand over to the private insurance industry hundreds of billions of dollars when they continue to demonstrate their gross incompetence and nearly criminal negligence in their coverage decisions?
Maybe we’re more to blame since we continue to agree to fund their expensive, wasteful administrative bureaucracies that are making decisions that kill people. Obviously we would never accept that if we had our own public program.

The future of Medicaid is not in good hands

Medicaid commission draws unusual interest
By Julie Rovner
Reuters
May 13, 2005

When it comes to the Medicaid health program for the poor, the question in Washington has moved from whether to cut the program to how.

Six Republican and six Democratic senators wrote Health and Human Services Secretary Michael Leavitt earlier this week, urging that he turn the entire enterprise over to the nonpartisan Institute of Medicine.

That, however, is apparently not what the administration has in mind.
(Health and Human Services Secretary Michael) Leavitt said Wednesday he is moving “rapidly” to establish the commission, which sources say he will appoint himself rather than delegate the task to the IoM.

http://www.reuters.com/newsArticle.jhtml?type=domesticNews&storyID=8485696

And…

New Panel Will Study Medicaid With Eyes Toward Big Changes
By Robert Pear
The New York Times
May 12, 2005

The commission will have up to 15 voting members and 18 nonvoting members. The voting members will all be appointed by Michael O. Leavitt, the secretary of health and human services. Mr. Leavitt rejected bipartisan Congressional pleas for an independent commission under the auspices of the National Academy of Sciences.

http://www.nytimes.com/2005/05/12/politics/12medicaid.html

And…

Kaiser Daily Health Policy Report
May 10, 2005

Senate Majority Leader Bill Frist (R-Tenn.), speaking on the Senate floor before the budget was approved, said Leavitt will appoint the commission in a manner that “represent[s] a broad range of ideas and points of view.” He added that the commission will be “a fair and balanced forum to discuss the needs and challenges of the Medicaid system.”

http://www.kaisernetwork.org/daily_reports/rep_index.cfm?DR_ID=29943

Comment: The decision has already been made that the underfunded Medicaid program will be cut further. The process will be personally supervised by HHS Secretary Leavitt rather than being submitted to a highly credible, independent source: the Institute of Medicine. Secretary Leavitt’s decision is particularly alarming since he has a track record on his approach to reducing Medicaid spending. When he was governor of Utah, he eliminated coverage for hospitalization and specialized services.

But we have the assurances of the Senate Majority Leader, Dr. Bill Frist, that the commission will be “fair and balanced.” It is ironic that Dr. Frist chose the registered, trademark phrase of Fox News. Since “Fair and Balanced” has been reduced to a mere trademark label, it seems that this absolves Fox from being either fair or balanced.

The question is, does Dr. Frist believe that this absolves Secretary Leavitt from the responsibility of being fair and balanced? Or is he acknowledging, tongue-in-cheek, that the whole process is a farce and cannot lead to constructive change? Unfortunately, based on his own track record, it appears that Dr. Frist is supporting an unfair and imbalanced process that portends a bleak future for Medicaid patients.

The disturbing decline of primary care

Career Plans for Trainees in Internal Medicine Residency Programs
By Richard A. Garibaldi, MD, Carol Popkave, MA and Wayne Bylsma, PhD
Academic Medicine
May 2005

Primary care is in crisis. Over the past five years, there has been a significant trend among medical students to move away from internships in primary care disciplines and to select, instead, residency programs oriented to subspecialty training.

In 1998, 54% of PGY3s (in internal medicine programs) planned to practice general internal medicine compared with 27% in 2003. Strikingly, in 2003, only 19% of PGY1s (in internal medicine programs) planned to pursue careers in general medicine.

Many reasons for the decline in interest in generalist careers have been described. These include both positive features that are attracting residents to subspecialty careers and negative forces that are perceived by medical students and residents that make general internal medicine and primary care less appealing. The positive features attracting residents to subspecialty careers include the intellectual content of the subspecialty field, technologic innovations, increased prestige, controllable lifestyle, a growing demand among consumers for subspecialty care, and higher income potential. Conversely, the negative factors making primary care less appealing include the trainees’ perceptions of job dissatisfaction among primary care practitioners, lack of prestige, indebtedness, lower income potential, greater stress, bureaucracy, changing consumer preferences away from primary care, and a lack of clarity about the future of primary care practice as other types of providers enter the field.

http://www.academicmedicine.org/cgi/content/full/80/5/507

Not only has there been a shift from general internal medicine to the medical subspecialties, there has also been a dramatic decline in the number of graduating medical students selecting family medicine residencies. The graph depicted at the following link demonstrates the trends in enrollment in all primary care residencies: http://www.graham-center.org/x468.xml

Comment: The following two principles have been well documented in the health policy literature. A strong primary care infrastructure improves quality and reduces costs. Excess capacity in specialized services significantly increases costs without a commensurate improvement in population health care outcomes.

This disturbing trend in the shift of enrollees from primary care into subspecialty and surgical programs is not good news for those concerned about the continuing escalation of health care costs, which is almost everyone. Not only are specialists’ fees higher, but their practice patterns increase the intensity of services. An appropriate capacity in specialized services is certainly desirable. Many have clearly benefited from the best that our high tech system has to offer. But the United States is unique in having excess concentrations of high tech, specialized services which are over-utilized, dramatically increasing costs without a demonstrable improvement in overall medical benefit.

Few from the health policy arena would disagree with the concept that these trends need to be reversed. But not enough is being said about how that might be accomplished. When you look at the reasons given by students for making their choices, it is difficult to imagine a simple program which might shift their interests.

But just imagine what might happen if we had a single system of funding health care. A single payer system budgets capital improvements not only to ensure adequate capacity but also to avoid the excess capacity that tends to result in excessive frequency and intensity of services. In a single payer system, health care professionals negotiate for reimbursement rates. There is no reason that negotiations could not also address some issues with the work environment. Most physicians who work within integrated health care systems find greater job satisfaction, and single payer financing is very conducive to the expansion of integrated systems of care. Also the administrators of a single source of funding would be in a position to pressure academic centers to make greater efforts to be certain that the ratio of trainees is appropriate to the needs.

Reforming the way we pay for health care certainly will not solve all of the problems that have resulted in the decline of primary care. But it would be a great start. You can accomplish much when you control the funds. Private plan administrators are accountable to their investors, but public program administrators are accountable to the taxpayers. Isn’t that much more reasonable since the taxpayers are also the patient-beneficiaries of the health care system?

Two-tiered Medicare?

Centers for Medicare & Medicaid Services
Ruling No. 05-01
May 3, 2005

TITLE: Requirements for Determining Coverage of Presbyopia-Correcting Intraocular Lenses that Provide Two Distinct Services for the Patient: (1) Restoration of Distance Vision Following Cataract Surgery, and (2) Refractive Correction of Near and Intermediate Vision with Less Dependency on Eyeglasses or Contact Lenses

In general, items or services covered by Medicare must satisfy three basic requirements: (1) they must fall within a statutorily-defined benefit category; (2) they must be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body part; and (3) the item or service must not be excluded from coverage.

A conventional intraocular lens (IOL) is covered when implanted following cataract surgery.

Medicare specifically excludes certain items and services from coverage, including eyeglasses and contact lenses. The Congress, however, has provided an exception for one pair of eyeglasses or contact lenses covered as a prosthetic device furnished after each cataract surgery with insertion of an IOL.

CONCLUSION

The statute specifically states that one pair of conventional eyeglasses or contact lenses furnished subsequent to each cataract surgery with insertion of an IOL is covered. A single presbyopia-correcting IOL essentially provides what is otherwise achieved by two separate items: an implantable conventional IOL (one that is not presbyopia-correcting), and eyeglasses or contact lenses. Although presbyopia-correcting IOLs may serve the same function as eyeglasses or contact lenses furnished following cataract surgery, IOLs are neither eyeglasses nor contact lenses. Therefore, the presbyopia-correcting functionality of an IOL does not fall into the benefit category and is not covered. Any additional provider or physician services required to insert or monitor a patient receiving a presbyopia correcting IOL are also not covered. For example, eye examinations performed to determine the refractive state of the eyes following insertion of a presbyopia-correcting IOL are non-covered.

Regardless of site-of-service for insertion of a presbyopia-correcting IOL, the beneficiary is responsible for payment of physician services attributable to the non-covered functionality of a presbyopia-correcting IOL inserted following cataract surgery. In determining the physician service charge, the physician may take into account the additional physician work and resources required for insertion, fitting, and vision acuity testing of the presbyopia-correcting IOL compared to insertion of a conventional IOL.

The beneficiary is responsible for payment of the charges for physician services that exceeds the physician charge for insertion of a conventional IOL following cataract surgery.

http://www.cms.hhs.gov/rulings/CMSR0501.pdf

Comment: One of the more difficult issues facing Medicare administrators is deciding which technological advances should be included in the Medicare program, considering the continuing escalation of health care costs.

Everyone would agree that expensive technology that fails to provide any significant benefit should be excluded from coverage. Likewise, technology that has been proven to be beneficial, and is not inordinately expensive, should be included. The difficult decisions involve technology that is very expensive and provides only a questionably marginal benefit. Most would agree that such care might reasonably be excluded in the absence of adequate evidence-based benefit, unless you just happened to be the individual who wanted access to that service. But the line must be drawn, and this seems to be a sensible approach.

Where has the line been drawn with intraocular lenses (IOLs)? IOLs are covered when implanted in conjunction with cataract surgery, whereas eyeglasses or contact lenses are not covered for presbyopia. But there is an exception. One pair of eyeglasses or contact lenses is covered after insertion of an IOL following cataract surgery.

This ruling then goes on to make a very fine technical distinction between presbyopia-correcting IOLs and the post-cataract surgery eyeglasses/contact lenses. The IOL is covered, the eyeglasses are covered, but the functionality of the IOL that corrects presbyopia is not covered because it has been shifted from the eyeglasses to the IOL!

What is unique about this ruling is that it allows Medicare to pay an amount that a conventional IOL would cost, but it requires the patient to pay for additional costs and services for the presbyopia correction of the IOL.
Because these are excluded services, they may also be excluded from Medicare fee determinations. It can be anticipated that the additional out-of-pocket expense for the patient will be significant.

Thus enters two-tiered care within the traditional Medicare program. And we didn’t even have to go to the private Medicare Advantage options to accomplish it. Limited income patients receive outdated technology and one pair of eyeglasses to last a lifetime, whereas more affluent patients receive the latest technology which corrects their presbyopia for life.

This is a beneficial service which is not inordinately expensive. It should be completely covered by Medicare.

Now that the principle of a two-tiered Medicare program has been established, what might we anticipate? The cost of any new technological advance that is truly innovative (i.e., not a defined Medicare benefit) can be passed on to the patient, at retail prices, beyond the Medicare approved fees of the service without the new technology. Thus the wealthy will receive the benefits of the newest technology whereas those with modest resources will not: the definition of a two-tiered system.

We can get it right. With a universal social insurance program, all reasonably affordable, beneficial services can be made available to everyone with legitimate medical needs. Let’s fix Medicare, and then use it to cover everyone.

Health Care for All in Michigan

Michigan needs health care access for all:
Since a national universal system is not a reality, Michiganians must create local solutions to provide medical care for the uninsured and underinsured
Detroit News
detnews.com
Wednesday, May 11, 2005

By Irvin D. Reid

If you asked most Americans whether health care is a basic right, we emphatically would say yes. Unfortunately, this conviction has not translated itself into public policy. Citizens of this country are guaranteed many rights, but access to high-quality health care sadly is not among them.

While in most respects, this nation’s health care system is among the world’s best, millions of our citizens remain underserved — or not served at all. If you do not have money, however, the door to our health system may well be closed to you.

More than 43 million Americans are without health insurance, and this number is growing. All over this country, people who work hard every day often must choose between paying rent and buying food or obtaining health care for themselves or their families.

It is important to remember that most people who have no health insurance do have jobs. They are members of working-class families whose employers offer no health benefits, or whose expenses are such that health care must be a low priority. The inability of working men and women to obtain affordable health insurance is a consuming problem that is spreading beyond traditional minority populations.

While the lack of affordable health care is a statewide problem, it is a crisis in Detroit.

Twenty-two percent of Detroit’s residents are uninsured compared with 11 percent statewide. It gets worse if you add people who are eligible for Medicaid, the federal health care program for the poor. Then 52 percent of Detroit’s residents lack coverage or need government help compared with 22.5 percent statewide.

Only 35 percent of Detroit’s residents have commercial insurance; statewide, the figure is 63 percent.

Given recent trends in employer benefit givebacks, which affect all workers, it is likely that the health care problem of minority populations will become the problem of Americans across racial, ethnic and some economic lines. Our society continues to put a bandage on this problem when we should be taking steps to cure it.

From birth itself, urban children of color are at a disadvantage. Infant mortality rates are much higher than for whites, and blacks and Latinos are more likely to have low-birth-weight babies. An African-American infant has more than twice the risk of dying in the first year of his or her life than a baby born to a white mother. Nearly one in four Hispanic children misses at least one of the full series of vaccines against childhood diseases such as polio.

African-Americans lead the nation in heart disease, obesity, stroke, diabetes, cancers and kidney disease. African-Americans have a 60 percent greater risk of death or disability from stroke and coronary disease than whites.

Hispanics have twice the rate of diabetes as white Americans. African-Americans and Hispanics, who comprise 25 percent of the U.S. population, account for 55 percent of the reported AIDS cases.

African-American women have three times the rate of high blood pressure, and are 40 percent more likely to die from cardiovascular disease, when compared with white women. Hispanics have higher mortality rates due to cancer of the stomach and the cervix than non-Hispanic whites.

And then there is the cost of prescription drugs. Each of us has known or heard of individuals, not all of them minorities or low-income, who have postponed filling prescriptions because they simply are too expensive. Some take half the prescribed dosage to cut costs and as a result risk foregoing the benefits of their prescriptions.

When we read in the future about some brilliant new therapy or surgical technique, we should think about how many people, regardless of race, whose lives might have been saved who will not have access to it because their insurance will not cover it, or they lack insurance or they simply cannot afford it.

The issue of inadequate access to health care by the underinsured and uninsured should be addressed nationally. But with little hope of a national system of universal health care, workable local solutions must be considered.

Wayne State University medical faculty in their various roles in health delivery venues in Southeastern Michigan, primarily in the Detroit Medical Center, provided more than $150 million in uncompensated health care to local residents over a five-year period. Gov. Jennifer Granholm is supporting a provider fee for practicing physicians to relieve the financial burden on physicians who care for a disproportionate share of those on Medicaid. Hopefully, a bipartisan solution can be found soon.

We no longer can speak of civil liberties or human rights in this country without speaking of public health. Health care is either a right or it is a privilege. It is something that is yours simply by virtue of your membership in civilized human society, or it is a commodity available to those who can afford it. Most of us would say it is the former. Increasingly, it actually is the latter.

Irvin D. Reid is president of Wayne State University in Detroit. Send letters to The Detroit News, Editorial Page, 615 W. Lafayette, Detroit, MI 48226, (313) 222-6417 or letters@detnews.com.

Paying for health care for illegal immigrants

Payments to Help Hospitals Care for Illegal Immigrants
By Robert Pear
The New York Times
May 10, 2005

The Bush administration announced on Monday that it would start paying hospitals and doctors for providing emergency care to illegal immigrants.

The money, totaling $1 billion, will be available for services provided from Tuesday through September 2008. Congress provided the money as part of the 2003 law that expanded Medicare to cover prescription drugs, but the new payments have nothing to do with the Medicare program.

Dr. Mark B. McClellan, administrator of the Centers for Medicare and Medicaid Services, said a hospital should not directly ask a patient “if he or she is an undocumented alien.”

The Bush administration abandoned a proposal that would have required many hospitals to ask patients if they were United States citizens or legal immigrants.

http://www.nytimes.com/2005/05/10/politics/10health.html

From CMS: Section 1011. Federal Reimbursement of Emergency Health Services Furnished to Undocumented Aliens:
http://www.cms.hhs.gov/providers/section1011/

Comment: Using federal tax funds to pay for medical care for undocumented residents is certainly highly controversial and will provoke considerable comment, much of it negative. But another perspective should be included in the debate.

California will be receiving the largest allocation of these funds, representing the magnitude of the immigrant problem within the state. When the participants in the Health Care Options Project studied the various models of reform for California, the costs of care for undocumented residents were a consideration.

The team of physicians from the University of California at San Francisco that developed one of the single payer models elected to include undocumented residents in their proposal. An independent microsimulation of their model demonstrated that truly comprehensive care could be provided for absolutely everyone, including the undocumented, while reducing health care costs for Californians by over $7 billion.

If the undocumented were excluded from coverage, the costs of these emergency services would still have to be picked up, either by cost shifting or through government subsidization. Providing affordable access to routine care and preventive services would offset at least part of the costs of expensive emergencies that could have been averted through the provision of more timely and appropriate care, not to mention reducing the costly administrative burden of a fragmented system of funding care. Besides, if establishing a single system meant that we had a more effective and less expensive system for the rest of us, would we really begrudge the fact that everyone would be included?

The physician authors of the UCSF proposal (J. Kahn, V. Lingappa, K. Farey, T. Bodenheimer, K. Grumbach, D. McCanne) believe that everyone should have affordable access to health care. It is reassuring to see that Congress and the Bush administration agree, to a certain extent, that no person should be refused care when really in need, and that the government should use public funds to help ensure access to that care.

In no way have we begun to resolve the debate over undocumented immigration. But, with the support of a conservative government, we have moved much closer to the principles that everyone should have access to health care, and that it should be funded in a more equitable manner. That’s a great leap forward on the path toward health care justice.