Resource – Page 1107

Healthcare Debate on “Democracy Now”

AMY GOODMAN: We’re joined by Dr. Steffie Woolhandler, association professor of Medicine at Harvard University, co-director of the Harvard Medical School General Internal Medicine Fellowship program. Also, Sally Pipes, president of the San Francisco based Pacific Research Institute, author of the new book, Miracle Cure: How to Solve America’s Health Care Crisis and Why Canada Isn’t the Answer. Sally Pipes, let’s begin with you. You’re assessment of what President Bush has proposed as well as John Kerry?

SALLY PIPES: Yes. Good morning, Amy. I grew up in Canada under Canadian health care, and now the average wait in Canada from seeing a GP to a specialist has gone from in 1993 from nine weeks to 17.9 weeks. So, we have two different plans here. President Bush’s plan is talking about, you know, giving patients and doctors control over the health care rather than government bureaucrats. He’s looking at expanding health savings accounts to provide affordable coverage to individuals and businesses. He’s talking about making changes in tort reform to reduce malpractice awards. He is setting up association health plans so small businesses can band together and provide coverage for workers. Plus refundable tax credits for low income American individuals and families. On the other hand, presidential candidate, Kerry, his plan in my estimate and those of others, economists that I work with, is trillion dollars over ten years. He is saying that he will get this money through rescinding the Bush tax cuts. That would really only cover one-third of the cost. But the real issue in the Kerry plan is he would move the American people more to a Canadian single payer style system. This is just one step. It’s really talking about putting millions of middle income Americans into Medicaid, the federal state health plan for the poor, and putting millions of more Americans into a system of managed competition, which is similar to what Hillary Clinton proposed more than a decade ago. I’ll just make one point on that and you know, when you look at President Clinton and his terrible heart problem, he went in to the doctor on a Thursday, and he had an angiogram Friday, on Monday, he had quadruple bypass. If he lived in Canada, or if Hillary Clinton’s plan had passed, he would be looking at an average wait of 3.4 weeks from seeing a GP to seeing a cardiologist, another 2.1 weeks for having urgent bypass. If it wasn’t that urgent, it would be 10.7 weeks. His plan really is putting more and more government into our lives. The Bush plan is really talking about letting consumers be empowered to take control over their health care and I think that in my opinion, having grown up under Canadian health care, this is the option that Americans will like. You cannot take the American people into that program. It’s just a government program. It’s just not going to work.

JUAN GONZALEZ: Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard University, your response to the Bush plan and also your sense of what Senator Kerry’s plan entails.

DR. STEFFIE WOOLHANDLER: I’ll get to Bush and Kerry in a minute, but I cannot let the falsehoods about Canada stand. When people look scientifically at waits in Canada the average wait for urgent heart surgery is one day. The average wait for non-urgent heart surgery is 17 days. So, Sally’s numbers come from a crackpot research organization that has no credibility, and her organization has been spreading those numbers around and they’re not true. The truth is Canadians have complete free choice of doctor or hospital. They live
two to three years longer than Americans, and they’re spending about half of what we do on health care. The reason is that they have so much administrative efficiency by getting rid of the insurance companies and their paperwork, they can afford universal care. Now, our group, Physicians for a National Health Program, which is a leading advocate of single payer health care, does not advocate the Canadian system. We advocate Canada Deluxe. We advocate spending the same amount what they’re spending now twice what they have in Canada, but achieve the administrative efficiency and universal coverage of Canada, so we could cover everyone with no waits of any type. But getting back to the question of Bush and Kerry, Mr. Kerry gets us less than halfway there, even if his plan is successful. He will leave 17 million Americans with no health insurance. Let’s not pretend that’s really universal health care.

Mr. Bush’s plan is actually quite a bit worse. He intends to pour money into tax credits which will not succeed in covering people. We know that because Mr. Bush is modeling his plan after an existing tax credit program called the Trade Adjustment Assistance Act, where less than 2% of eligible people have decided to take the tax credit. The reason is that Bush is talking about offering a tax credit of $3,000 for a family to buy health insurance. But the average family policy in this country costs $10,000. This would leave a family with $7,000 they would have to take out of their own pocket in order to get health insurance. And obviously, a low income family, an unemployed family, is not in a position to pay an additional $7,000 out of their pocket for health care. Hence the tax credits are not going to be sufficient to allow low income people to buy health insurance and they’re simply not going to get any coverage out of Mr. Bush.

JUAN GONZALEZ: Sally Pipes, your response, especially on the whole issue of the administrative cost savings as a result of the plans of Senator Kerry; and doesn’t a bigger, more organized system with one buyer have power to control prices better and to prevent health care costs from spiraling?

SALLY PIPES: The Canadian system is expensive. First of all, you’re comparing apples with oranges. Canada doesn’t include the capital costs of hospitals in their numbers.

DR. STEFFIE WOOLHANDLER: That isn’t true.

SALLY PIPES: Excuse me. Canada has the third most expensive health care system in the world after the United States and Switzerland. Canadians, if you look on websites, you will see the stories of Canadians who are having to wait, who cannot get doctors and are leaving Canada to come to the United States. There’s a woman in Quebec, who is suing the Quebec government in a malpractice suit for $37 million. She’s suing on behalf of 10,000 Quebec breast cancer patients who had to wait over the limit of eight weeks to get radiation oncology. The Canadian Medical Association came out with a report two weeks ago saying that over 50% of Canadians are incredibly dissatisfied with the health care that they are getting, just look on websites and see the number of Canadians who are upset. And Canadians use America as a safety valve. Look at the border towns. Senator Ed Lawson, who was head of the Teamsters union, and became national senator, when he was diagnosed two years ago with heart situations similar to president Clintons, they told him to wait, even a person of such importance as himself, left and came to — went to Seattle, Washington, because he didn’t want to wait two weeks to get an angiogram. So,you know, I’m not a crackpot institute. That was very insulting. I have done a lot of work. I have worked in Canada on this issue. There is tremendous work done by the Frasier Institute in Canada on hospital waiting lists. It’s all scientifically done. The administrative costs in Canada, you’re not comparing apples with apples it is the third most expensive system in the world.

In the United States today, 45% of our health care dollars are actually in the government system between Medicaid, Medicare, the State Children’s Health Insurance Program and things like that.

DR. STEFFIE WOOLHANDLER: I’m not calling Sally a crackpot. I’m calling Frasier Institute that she quotes extensively crackpot. This is the group that thinks we ought to privatize the whales. This is a group that thinks that we should abolish medical licenses.

SALLY PIPES: This is a group that thinks there should be private options in Canada. I think a lot of people in the United States think that Canada

DR. STEFFIE WOOLHANDLER: Sally, I let you talk, okay. Now it’s my turn. The reality is Canada spends half of what we do. I happen to have published a definitive article on the administrative costs in the New England Journal of Medicine. I know what the Canadian hospital cost reports look like. I know what Canadian cost reports look like. Canada spends half of what we do. That’s what the Organisation for Economic Co-operation and Development and the UN say. And that’s the reason why they do have some waits for elective services in Canada. Elective services. Do think that’s a good thing? No. I don’t think we should have to wait for things. But if we have a Canadian style system, and spend twice as much money, then there’s no reason to have any waits. That’s not just my opinion, that’s also the opinion of the US General Accounting Office and the US Congressional Budget Office.

AMY GOODMAN: I’d like to ask Sally Pipes, what do you think is good about John Kerry’s proposal?

SALLY PIPES: Well, I don’t think that there are good things about it. I think the numbers came out from the Census Bureau saying that 45 million America ns do not have insurance. You have to look and analyze who are the 45 million Americans. Because 16% of them are people who are earning over $75,000. 33% are people who are earning over $50,000. Just because you don’t have health insurance does not mean that you don’t get health care. There’s a lot of money spent by individuals who don’t have health insurance who go out and buy their own. They pay out of pocket for their health care. Really, 8 million Americans are people who are chronically uninsured, and low income. Those are the people that I think that the government needs to take care of. And I definitely believe that there are — you know, children and low income families that do need care. I think for the rest of people, we need to open up system to empower consumers to get the best health care they can. People, when you look at any government program, most people do not like the DMV. The post office became more competitive when it opened up to competition from fed ex and UPS and a variety of things. Competition is what makes the world go around. Canadians do not have any form of competition. Any private coverage in Canada is outlawed under the Canada Health Act.

JUAN GONZALEZ: Let me ask you, Sally Pipes, drugs, the cost of prescription drugs have become a huge part of health care costs in this country, and if our system, as it is now structured, is doing so well, why are so many Americans trying to get to Canada, or to Mexico to buy prescription drugs?

SALLY PIPES: Today in America, Americans spend 1% of their income on prescription drugs. In the 1960’s Americans spent 1% of their income on prescription drugs. There are a number of drugs that are available in Canada– in the United States that allow us to — many — the drugs today allow us to live longer and healthier lives. From 1997 to 1999, out of 100 new drugs that became available in the United States, only 43 of them made it onto the formular
y in Canada. A lot of the top drugs in the United States that are used in Canada are generically available in the United States, and are cheaper, but the real issue here about prescription drugs, Americans want lower prices for prescription drugs. The reason they’re — the drugs are lower in Europe and Canada is because of price controls. So, what people really want in America is price controls on drugs, which is going to have a negative impact on research and development in this country, and innovation. New drugs have reduced costs for hospital stays because people can use drugs now for ulcers, for instead of having gall bladder surgery. We’re reducing costs by allowing Americans to have access to the greatest drugs and innovation in the world.

JUAN GONZALEZ: Dr. Steffie Woolhandler, I’d like you to respond to the issue of drugs and the differences between Canada and the United States.

DR. STEFFIE WOOLHANDLER: I want to remind that you, Canadians do live two to three years longer than Americans. That was not true before they went with National Health Insurance. That’s because the National Health Insurance program has allowed them good access to all types of care, including drugs. Canadians, about half of Canadians do get their drugs through their insurance. But all Canadians benefit from a system whereby the government negotiates with drug companies for lower prices. So, Canadians are paying about 60 cents on the dollar that Americans pay, and they’re paying only 60% of what we pay for drugs, and they really are the same drugs. Sally’s idea that you cannot get drugs in Canada is simply not true.

SALLY PIPES: I’m not saying you can’t get drugs.

DR. STEFFIE WOOLHANDLER: They have access to the same drugs that we do, they can just afford them. And similarly, Sally’s contention that uninsured people get all of the health care they need, doesn’t make common sense, but is also belied by a huge body of literature. Most recently, Ayanian colleagues published a study looking at people aged 55 to 65 who have no health insurance, and 10% of the people died over an eight-year period. They died at 33% higher rate than people who had insurance. It’s just common sense that if you don’t have a way to pay for care, you are going to get less of it, and it’s going to impact your health and maybe make your die younger.

AMY GOODMAN: Who benefits under Bush’s plan?

DR. STEFFIE WOOLHANDLER: Well, there’s a big benefit to some middle income taxpayers who end up taking a tax credit where they already had insurance. Now, they can get a tax credit that helps them pay for it. So, there’s some benefit to that. He’s very big, in general, Bush’s policies are very big with the insurance industry and drug industries. Because he has a very hands-off approach, where all of the government taxpayers do is just send more money into the system. There’s no attempt by the government to regulate things or make them more fair.

AMY GOODMAN: Sally pipes?

SALLY PIPES: Well, I’d like it just comment on one thing. Canada is a country of 32 million people, fewer than in the state of California. We have much less ethnically diverse. We don’t have the minority low income populations that are in the United States. If you compare white Canadians to white Americ ans, Americans are now living longer than Canadians. I think that the Bush plan

DR. STEFFIE WOOLHANDLER: No, that isn’t true, Sally. It’s simply not true. Canada Health Survey .

AMY GOODMAN: We actually have to leave it there. I want to thank you both for being with us. I know that you both have to race off anyway. Sally Pipes, president of the San Francisco based Pacific Research Institute. Her new book is called Miracle Cure: How to Solve America’s Health Care Crisis and Why Canada Isn’t the Answer. Dr. Steffie Woolhandler, Associate Professor of Medicine at Harvard University, and co-founder of Physicians for a National Health Program.

On health, a clear choice between Bush, Kerry

On health, a clear choice between Bush, Kerry
October 17, 2004

The health care crisis is back. It’s a lively topic in the presidential campaign.

Eleven years after the Clintons introduced their super-complex plan to revamp health care, the problems of rising costs and increasing numbers of uninsured have only gotten worse.

More than 43 million citizens under the age of 65 do not have health insurance – up from 38 million a decade ago. And fewer employers provide health insurance plans at all. Four years ago, 65 percent of employers offered health plans. Today it’s 61 percent.

In addition, health care costs continue to skyrocket – well beyond the rate of inflation. Since 2001, premiums for family coverage have risen 59 percent, according to a recent Kaiser Family Foundation survey. That’s five times the rate of inflation and well above the increase in income for the average worker. For employers, it adds to the cost of doing business and discourages hiring new employees.

And the trends are ominous. Spending on health care now accounts for almost 15 percent of the nation’s gross domestic product – and rising. Japan and Great Britain spend 8 percent. And the United States has fallen behind other nations in significant measures of health. For instance, the infant mortality rate for black Americans is double the rate for whites and four times that for babies in Japan.

The health care proposals by President George W. Bush and his Democratic challenger, Sen. John Kerry, are dramatically different in type and scale.

While Kerry’s plan is far short of the scope of the Clinton administration’s proposal – and not a Big Government plan as Bush charges – it is ambitious and expensive. Kerry wants to cover 95 percent of the population; he estimates it would cost $653 billion over nine years. He would pay for it by rolling back the tax cuts for people earning more than $200,000 a year.

Kerry’s plan includes tax credits to small businesses to enroll in the federal employees health care system – a group of private plans. He would lower premiums by having the government re-insure for catastrophic coverage – the fastest growing aspect of health insurance. And he would extend government coverage to all children not covered.

Bush’s plan is far less ambitious. It basically involves offering health savings accounts that would allow individuals to deduct the costs of health insurance from their taxes. The major problem with his scheme is that middle-income and working-class families might not be able to afford to pay into the accounts.

It would certainly benefit the wealthy. And the Kaiser foundation estimates it would only reduce the uncovered rolls by 1.8 million.

Bush says Kerry’s plan would cost three times what Kerry estimates and require a tax increase. Maybe so. And the Kerry plan would be more effective in providing additional coverage than reducing medical costs. But Bush’s plan doesn’t meet the challenge of either rising costs or lack of coverage.

Inevitably, reducing costs will involve tough moral and ethical questions, the kind that politicians running for office aren’t willing to deal with. The nation has developed more medical technology than it can afford. The key issue in controlling costs will be: who gets what type of care, and when. That does imply rationing.

This much is clear: The next president will have to step up to these issues. In our view, the Kerry plan offers more hope for making progress.

Controlling Health Care Costs

By Paul B. Ginsburg, Ph.D.
The New England Journal of Medicine
October 14, 2004

In reality, there are four basic options for slowing the trends in health care spending: one can increase the efficiency of health care delivery; increase the financial incentives for patients to limit their use of medical services; increase the administrative controls on the use of these services; or limit the resources available to the health care system.

Government may be able to contribute to the efficiency of the health care system by supporting the development and installation of information technology to improve the coordination of patient care… Greater adherence to the practice of evidence-based medicine, additional research on the effectiveness of medical treatments, and greater assessment of technology before it is used outside research settings may all lead to gains in efficiency…

In recent years, employers have taken such steps as increasing deductibles in order to shift more costs to employees, giving them a financial incentive to use fewer services. Innovation is under way in this area: new benefit structures have been developed, including consumer-directed health plans, which typically have employer-funded spending accounts tied to insurance policies with a large annual deductible that exceeds the annual contribution to the account. Having patients share more costs can benefit consumers when it leads them to forgo care that has very limited benefits. But when the tools are used bluntly – as when they are applied equally to care that is deemed essential and care that is considered to be more discretionary – they can pose a barrier to important care or cause financial hardship for patients with low incomes or substantial medical needs.

An approach stressing administrative controls, relying on tools such as restrictive provider networks, prior authorization for services, and payment of providers on a capitated or episode basis, was used extensively by managed-care plans but proved highly unpopular.

Restricting the resources that go into the medical care system and the prices paid to providers is an approach that has been used extensively in Canada and Western Europe but has never gained much of a foothold in the United States. Attempts to regulate facility expansion and hospital rates were common in the United States during the 1970s but declined with the expansion of managed care and increased competition in medical care.

We can only hope that whoever is elected president will move beyond campaign-trail rhetoric and provide the leadership needed for a candid national discussion about health care costs. If not, we will find ourselves on a downward spiral, as more and more resources are used to pay for the health care of fewer and fewer Americans – a potentially intolerable situation.

http://content.nejm.org/cgi/content/full/351/16/1591

Comment: Quiz time. There are many ways to control health care costs. Regular readers of the Quote of the Day messages should be able to identify which measures will slow the growth of health care costs while ensuring that each patient will have affordable access to higher quality health care services, and which measures will slow the growth of costs by making care unaffordable to individuals with significant health care needs, while failing to direct our resources to care which is less costly but with better outcomes.

You have ten minutes to select the beneficial approaches and discard those that are detrimental. When finished, aggregate your answers and then share them with others as you initiate your own efforts at grassroots reform. Without your participation, reform won’t happen.

What Would An Employer's Response be to California's Employer Mandate?

Employers’ Responses To A Play-Or-Pay Mandate: An Analysis Of California’s Health Insurance Act Of 2003
By Anna D. Sinaiko
Health Affairs – October 13, 2004

California, with 20 percent of its population uninsured and an unemployment rate of 6.2 percent, recently enacted the Health Insurance Act (known as SB 2), a play-or-pay employer mandate to expand health insurance coverage to a portion of the state’s working uninsured population. This law requires employers to either “play,” by providing employee health benefits that meet a minimum standard, or “pay” a fee to the state to cover workers under a state-sponsored program. Specific provisions of this program are still being determined. Although the law is scheduled to be phased in starting in 2006, a coalition of business groups is working to overturn it by referendum in November 2004.

With the passage of SB 2, California has brought the employer mandate back to the forefront of the health policy reform debate. Although state governments can mandate that employers provide coverage without committing public funds, someone must pay for the newly provided health insurance. In the best-case scenario, workers will value health insurance at more than its cost, and the combination of health insurance and lower wages will make workers better off without any adverse effects on employment or product prices. A more likely scenario is that some of the cost of health insurance will be passed to consumers, some felt by workers as unwelcome wage reductions, and some avoided by firms as they restructure their workforces. In California, workers at firms not offering benefits are more likely to be young males earning less than workers at firms that offer insurance; SB 2 will affect this group most adversely.

As employers restructure their workforces, fewer would-be-eligible workers will be offered health insurance. Although SB 2 will bring eligibility for health coverage to a portion of the uninsured in California, it will be lower than the estimated 1.07-1.56 million that researchers have projected. Moreover, because SB 2 does not include an individual mandate requiring workers to take up the coverage offered by their employers, some employees will decline employer-sponsored coverage, and fewer workers will be insured. This finding is not unique to California; similar results would be expected in other states.

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.469

Comment: Proposition 72, on California’s ballot next month, will allow voters to accept or reject SB 2, the play-or-pay employer mandate.

An employer mandate is the wrong solution to the problem of the uninsured. It reduces wages of those who were previously uninsured, with the greatest negative impact on lower income individuals. It perpetuates regressive tax policies in which higher income individuals receive a greater tax benefit than do lower income individuals. It threatens loss of employment as employers adjust hiring and work requirements to minimize the financial impact of the mandate. It results in higher prices which impairs competitiveness in national or international markets. In can result in adverse selection as decisions are made to avoid pools that concentrate higher cost individuals. Workers may decline coverage because of the consequential reduction in their take-home pay.

The problem that the voters face is that Proposition 72 is the only current, politically feasible proposal that will increase health care coverage. It would provide health insurance for close to one million of California’s six million uninsured. The single payer proposals, Kuehl’s SB 921 and Conyers’ HR 676, are locked in political limbo. And any promise of the presidential candidates for bona fide reform cannot become reality until the Congressional partisan rift is mended, a highly unlikely event in the next decade or two. The most realistically feasible approach would be to expand Medicaid and SCHIP, but that is highly unlikely until the deficit is reduced by tax increases, at a time when no politician would dare utter those words.

Although Proposition 72 is the wrong solution, it is the ONLY solution, at the right time and the right place. Californians need to approve it and then move on with our grassroots efforts to create the political feasibility for the adoption of a single payer system. If we work hard enough, maybe we won’t have to wait a decade or two for genuine reform.

What Would An Employer’s Response be to California’s Employer Mandate?

Employers’ Responses To A Play-Or-Pay Mandate: An Analysis Of California’s Health Insurance Act Of 2003
By Anna D. Sinaiko
Health Affairs – October 13, 2004

http://content.healthaffairs.org/cgi/content/abstract/hlthaff.w4.469

Comment: Proposition 72, on California’s ballot next month, will allow voters to accept or reject SB 2, the play-or-pay employer mandate.

Hewitt Gives Little Hope of Containing Costs

U.S. Companies and Employees Continue to Struggle With Double-Digit Rate Increases
Hewitt Associates – Press Release
October 11, 2004

On average, Hewitt forecasts that companies will experience 2005 cost increases of 11.5 percent for health maintenance organization plans (HMOs), 10.5 percent for traditional indemnity plans, 11 percent for preferred provider organizations (PPOs) and 11.5 percent for point-of-service (POS) plans, with projected employee contribution increases of 15 percent across all plan types.

That means from 2004 to 2005, the average cost per person for major companies will increase from $6,519 to $7,269 for HMOs; $6,823 to $7,573 for PPOs; $7,192 to $8,019 for POS plans; and $6,793 to $7,506 for indemnity plans, according to Hewitt’s database of more than 2,000 health plans in 139 U.S. markets, including 300 major employers and more than 18 million health plan participants.

“While there are many different variables that factor into regional health care cost increases, one of the most powerful drivers is the level of consolidation in the market,” added (Hewitt’s national health care practice leader Jack) Bruner. “Plans and providers continue to merge in many cities, reducing the purchasing power and number of options available to employers.”

http://was4.hewitt.com/hewitt/resource/newsroom/pressrel/2004/10-11-04.htm

And…

Health costs to rise 11.3%, group says
By Kim Morris
Detroit Free Press
October 12, 2004

…costs are expected to increase between 8 and 12 percent in each of the next five years, said Jeff Nielson, senior benefits consultant in Hewitt Associates’ Detroit office.

http://www.freep.com/money/business/ebenes12e_20041012.htm

Comment:
According to Hewitt, market consolidation has reduced the impact of competitive pricing resulting in higher health plan premiums, and there is no relief in sight. Private marketplace plans continue to prove that they are not capable of controlling health care costs.

It’s time to replace our highly flawed, fragmented system of funding care with our own monopsonistic, single payer purchaser. That’s the only way that we are going to get the level of health care spending right, both for patients and for health care providers.

Drug Makers Spend More on Stock Dividends Than Research, Analysis Indicates

During the past 18 months, the nine largest pharmaceutical companies have spent a greater percentage of their money on dividends for shareholders and on company stock buy-backs than they have spent on research and development, according to a Banc of America Securities analysis, USA Today reports. According to the study, the nine drug makers have returned about $56 billion to investors during the past six fiscal quarters. At Pfizer, the world’s largest pharmaceutical company, $22.2 billion was spent on stock buy-backs and dividends during that time period — about 210% the amount spent on R&D. Merck returned $7.3 billion, or 143% of R&D spending. Despite the amount of dividends for investors, share prices only grew by 5% during the study period. The study comes as rising prescription drug prices have made drug makers’ R&D expenditures “a political lightning rod,” according to USA Today. While the drug industry maintains higher U.S. prices are necessary to fund research of new drugs, critics say “the industry has plenty of money” for R&D and concentrates too much of its research on copycat drugs instead of innovative treatments, USA Today reports (Appleby, USA Today, 10/11).

Health Experts to Debate National Health Insurance

Released by University Relations 12 October 2004
Contact: ISU Continuing Education and Conferences, 208-282-3155 or
800-753-4781.

Nationally Renowned Heath Experts
To Debate National Health Insurance at ISU

Pocatello – Should the United States have a national single-payer health insurance program?
That is the question that will be debated by two nationally renowned experts at 7 p.m. Oct. 21 at the Idaho State University Pond Student Union Building Salmon River Suite as a keynote address of the 17th annual Idaho Conference on Health Care.

The debate features Dr. Stephanie, an associate professor of medicine at Harvard and co-director of the Harvard Medical School General Internal Medicine Fellowship program, and Dr. Jane Orient, executive director of the Association of American Physicians and Surgeons (AAPS). “We pay too much for health care. More than any other industrialized nation, 78 percent more per capita than our nearest competitor Germany,” said Dr. William Woodhouse, physician, associate director of the ISU Family Practice Residency Program, and member of the health conference planning committee that organized the debate. “We can’t afford it. One in five Americans are uninsured and employers are increasingly unable to pay for employee health care and still stay competitive in the world market.

We don’t get what we pay for. Despite the huge cost we rank in the lower half or near last among industrialized countries for most commonly used health care quality outcomes.” Woolhandler and her organization, Physicians for a National Health Program, contend that a single payer national health insurance program is the answer to these problems.

Orient and her organization, the Association of American Physicians and Surgeons (AAPS), reject single payer national health insurance and assert that the answer lies in our current free-market system. “Both speakers are very strong, nationally-known proponents of their respective viewpoints. I expect a vigorous debate on this critical topic,” Woodhouse said.

Orient’s group, the AAPS, has been a voice for private physicians since 1943, and supports the sanctity of the patient-physician relationship, traditional medical ethics and free-market principles. Orient is a board-certified internist in solo private practice since 1980. She is author of the book “Your Doctor Is Not In: Healthy Skepticism about National Health Care.”

Woolhandler’s organization attempts to educate physicians, other health workers, and the general public on the need for a comprehensive, high-quality, publicly-funded health care program, equitably accessible to all residents of the United States. Equitable accessibility requires, in the view of PNHP, removal of the barriers to adequate health care currently faced by the uninsured, the poor, minority populations and immigrants, both documented and undocumented.

The debate is just one of many presentations of the health conference running Oct. 20-22 at ISU. On the theme “We Can Do Better,” this year’s conference will delve into a variety of topics presented by nationally recognized health care authorities. The event will feature health speakers on everything from the risks of fast foods to doping by athletes.”Once again, we have an extremely rich agenda with speakers who will address health issues relevant to all sectors of health care, including the general public,” said Dr. Linda Hatzenbuehler, Dean of the ISU Kasiska College of Health Professions. “We want to stress what a varied and informative Idaho Conference on Health Care we have planned this year. The constituencies including students, practicing professionals and the general public.”

The conference keynote addresses are open to the public, but registration fees are required for most conference events, including plenary speeches. Continuing education units are available to professionals desiring them. For more information on the conference or to register, contact the ISU Office of Continuing Education and Conferences, 800-753-4781 or 208-282-3155, or visit http://www.isu.edu/chp/hlthconf/.

###

ICHC Single payer events.
Thursday October 21, 2004

2:30 – ~4:30 PM: Reception / Activist work group
At home of Kellie and Bill Woodhouse, 1407
Juniper Hills Road*, Pocatello
Refreshments will be served
RSVP: Call Kellie at (208) 234-0973

7:00 – ~9:30 PM Idaho Conference on Health Care (see
www.isu.edu/chp/hlthconf for conference registration, accomodations, etc)
“Single Payer National Health Insurance – Is This the Answer?”
Steffie Woolhandler, MD (PNHP) vs Jane Orient, MD (Association of American Physicians and Surgeons)
This should be a very contentious debate. Both participants are very strong representatives of their viewpoints.
Salmon River Suite – Pond Student Union – Idaho State University

Friday October 22, 2004
9:45 – 10:45 AM “The HealthSystem Project”
Paul Ellwood, MD, Jackson Hole Group
Ballroom -Pond Student Union – Idaho State University

11:00 – 12:00 AM “We Can Do Better: The Future of the American Health Care System”

Panel discussion: Steffie Woolhandler, Jane Orient, Paul Ellwood
Clearwater Room – Pond Student Union – Idaho State University

Is NCQA's Goal of Equality Attainable?

National Committee for Quality Assurance (NCQA)
The State of Health Care Quality – 2004

From the Introduction:
NCQA is pleased to present its 2004 State of Health Care Quality report. This is the eighth such report NCQA has produced, and the fifth report in a row to find that performance on key measures of clinical quality has improved over the past year. For the 69 million people enrolled in the health plans that provided their performance data to help NCQA prepare this report, this trend is very good news; they can expect better care and better health outcomes.

But what of the rest of the health care system?

What of those with little or no access to care such as the 45 million people without health insurance? What of those who receive care through health plans that do not publicly report their performance? Using conservative estimates, this report finds that the performance of the rest of the system leaves much to be desired. Huge “quality gaps” exist, costing tens of thousands of lives, millions of illnesses and billions of dollars annually.

From the Summary:
Despite evidence of promising gains in certain sectors of the health care system, once again this year NCQA documented evidence of widespread, unexplained variation in quality that results in thousands of unnecessary deaths, tens of thousands of avoidable hospitalizations and illnesses and billions of dollars in lost productivity-hobbling an economy already encumbered by the ever-growing costs of health insurance.

Even as adherence to evidence-based care has improved in many health plans, there is cause for great concern that these gains could be erased in the years ahead. The trend toward PPOs and CDHPs, while holding great promise in terms of consumer engagement and harnessing of the Internet’s power, also relies more on patient decision making and less on aggressive care coordination.

http://www.ncqa.org/Communications/SOMC/SOHC2004.pdf

Comment: The abysmal quality of health care for the uninsured has been well documented. And it is no surprise that quality can be improved for those individuals who have comprehensive health care coverage. Clearly we need to enact changes that would ensure that everyone has comprehensive health care coverage.

What should alarm us about this report is the current trend in health care coverage. Because there is more flexibility in the design of PPOs (preferred provider organizations), premiums can be made more affordable by shifting costs to the beneficiary-patient. Also, the CDHPs (consumer-directed health plans) are designed to make patients more responsible health care shoppers by exposing them to higher out-of-pocket expenses. But as the NCQA report indicates, this trend places a greater emphasis on patient decision making at the cost of deemphasizing aggressive care coordination.

The great news about the NCQA report is that aggressive care coordination does improve quality outcomes. The NCQA report describes approaches to improve the identification of better outcomes through improved care coordination. A carefully designed system can be used to reward higher quality care. But PPOs and CDHPs, by shifting the direct spending decisions to the patient-consumer, also shift the responsibility for identifying quality to the patient. But our current fragmented system does not have the capability of providing readily accessible, easily understood data on quality variation. And limiting choice to health plans reduces the patient’s ability to have the more important choice of actual health care providers.

A single, universal system with truly comprehensive benefits would provide an infrastructure that would enable the promotion of inducements that would encourage aggressive care coordination. We have enough data already to know what would happen with a greater shift to CHDPs and PPOs. We do not need another decade of health policy experimentation ending with the inevitable impaired outcomes.

We also have enough data to know what a universal, comprehensive system would bring. Even the special interests opposing reform understand the vast superiority of the single payer model. So why do we continue to listen to and follow their rhetoric designed to protect their own interests? As we continue to postpone the inevitable, we are perpetuating suffering and death. The blood is on the hands of those who fail to act.

Is NCQA’s Goal of Equality Attainable?

National Committee for Quality Assurance (NCQA)
The State of Health Care Quality – 2004

But what of the rest of the health care system?

http://www.ncqa.org/Communications/SOMC/SOHC2004.pdf

M. Calon on the Critique of Wisconsin's Drug Cost Program

Marty Calon, RPh, of Baltimore, Maryland, responds to the critique of Wisconsin’s program to reduce drug costs for state employees:
I usually couldn’t agree more with your comments, but I have to disagree with some of what you say here. I am a pharmacist with long experience in the Department of Veterans Affairs with these prescription practices.

As long as drug companies persist in pricing by dose, whereby a 5mg tablet and a 10mg tablet cost the same, splitting tablets is a viable option, as long as it is not done without controls. The drugs which are suitable for splitting must be specified and selected, on the basis of (in order of priority) suitability for splitting (physically and clinically), cost, and amount of usage (no point in requiring splitting of drugs which are rarely prescribed).

Specifically, there has to be good clinical judgment or clinical evidence that the particular medication and dosage form is suitable for splitting, and there has to be a liberal exception mechanism for patients who cannot or do not wish to deal with the splitting. The splitting program also should be monitored to ensure that the drug therapy with the split tablets is producing the desired results, although this monitoring should be happening regardless of tablet splitting.

For example, SSRIs and sildenafil (Viagra) are ideally suited to splitting. It doesn’t even matter if the dose is not precisely divided, because the exact dose is simply not very important, which is true for many drugs. In the case of SSRIs, which have a long-term effect, it’s just about irrelevant whether the patient gets his precise dose every day; cumulatively, he’ll get the right dose unless the tablet is falling apart. Warfarin is a drug that probably should not be split if possible. Pharmacists have a good understanding of the physical composition of the tablets (coatings, sustained-release mechanism, etc) and their pharmacokinetic parameters to determine their suitability for splitting.

Many physicians don’t have the knowledge, cost information, or motivation to prescribe generically. The majority of medications that are available generically do just fine if the pharmacist selects reputable generic vendors. The handful of notable exceptions (warfarin, theophylline SR, phenytoin, etc) are the only ones that need be limited to brand-specific prescribing. Pharmacists are well-qualified to make these judgments and advise physicians and patients on generic substitution, especially as they have the cost and legal equivalence information that is often not disclosed to physicians.

One more point: Rational selection of the most cost-effective medication, and controlled and monitored therapeutic substitution, again with appropriate exception mechanisms, are even more effective ways to save money. Think of all the people who are taking expensive antibiotics for trivial infections (if they need them at all), and the patients who take expensive “non-sedating” antihistamines and unnecessary COX-2 inhibitors, because they are so heavily promoted. And let’s not even start with all the patients taking medications that they don’t need at all.

I agree that these are not long-term or ideal solutions, and I make no apologies for the so-called “Pharmacy Benefit Managers”, but–properly implemented–they are appropriate responses to the current realities of medication prescribing and its costs.

Don’s response:
I emphatically agree with Marty Calon’s comments. They are certainly applicable to the real world of today, although we would hope might be modified eventually to apply to the ideal world which we envision.

One point that I failed to make was to acknowledge the crucial role that the pharmacist plays as part of the medical team. And I want to emphasize that the role to which I refer is as a health care professional who assists the patient and his or her practitioner in matters regarding drug therapy. This is in sharp contrast to a pharmacy benefit manager (PBM) that is primarily a middleman working the system to maximize profits for the PBM organization. Pharmacists must always be an integral part of the professional medical team.

The other point that I want to reemphasize is that we need fundamental structural changes that will improve access and affordability of prescription drugs. The pharmacist’s role should be to assist with the selection of the most appropriate drugs that also offer the best value. As the paper by Dean Baker demonstrates (a “quote” last week), we need to revise the drug patent system to provide incentives for better value in drugs. But also, we need to use negotiated purchasing that would also eliminate gimmickry designed to enhance profits. And we need to place the pharmacist in a position of being rewarded for applying his or her professional skills, rather than being placed in a subservient role of enhancing the success of a PBM business entity.

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