By Dhruv Khullar, M.D., M.P.P.; William L. Schpero, Ph.D.; Amelia M. Bond, Ph.D.; Yuting Qian, M.S.; Lawrence P. Casalino, M.D., Ph.D.
JAMA, September 8, 2020

Key Points

Question: Was there an association between patient social risk and physician performance in the first year of the Merit-based Incentive Payment System (MIPS), a major Medicare value-based payment program?

Findings: In this cross-sectional observational study of 284 544 physicians, physicians with the highest proportion of patients dually eligible for Medicare and Medicaid had significantly lower MIPS scores compared with physicians with the lowest proportion (mean, 64.7 vs 75.9; range, 0-100; higher scores reflect better performance).

Meaning: Physicians with the highest proportion of socially disadvantaged patients had significantly lower MIPS scores, although further research is needed to understand the reasons underlying the differences in MIPS scores by levels of patient social risk.

From the Discussion

These results are consistent with prior research in other value-based programs, suggesting that clinicians and health care organizations serving poorer patients tend to have lower performance scores. Many value-based payment programs may thus penalize clinicians for social factors outside their control and inadvertently transfer resources from those caring for less affluent patients to those caring for more affluent patients—the so-called reverse Robin Hood effect.

While the Medicare Payment Advisory Commission has recommended eliminating MIPS in its current form, Congress has not provided any indication it intends to do so.

https://jamanetwork.com…

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Association of Clinician Health System Affiliation With Outpatient Performance Ratings in the Medicare Merit-based Incentive Payment System

By Kenton J. Johnston, Ph.D.; Timothy L. Wiemken, Ph.D.; Jason M. Hockenberry, Ph.D.; Jose F. Figueroa, M.D., M.P.H.; Karen E. Joynt Maddox, M.D., M.P.H.
JAMA, September 8, 2020

Key Points

Question: Did clinicians affiliated with health systems composed of hospitals and multispecialty group practices have better performance ratings than their peers under the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS)?

Findings: In this cross-sectional study of 636 552 clinicians with MIPS data for 2019 (based on clinician performance in 2017), those with health system affiliations compared with clinicians without such affiliations had a mean MIPS performance score of 79 vs 60 on a scale of 0 to 100, with higher scores intended to represent better performance. This difference was statistically significant.

Meaning: Clinician affiliation with a health system was associated with significantly better 2019 MIPS performance ratings, but whether this reflects a difference in quality of care is unknown.

From the Discussion

Whether the MIPS will meaningfully improve quality or reduce costs over time is unknown. Research on prior Medicare value-based payment programs in the outpatient setting, notably the Shared Savings Program and the Value-Based Payment Modifier Program, have produced mixed results, finding modest to no cost savings or improvements in the quality of care. Longer-term studies are needed to examine this program as future years of data become available.

https://jamanetwork.com…

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Editorial: Potential Adverse Financial Implications of the Merit-based Incentive Payment System for Independent and Safety Net Practices

By Carrie H. Colla, Ph.D.; Toyin Ajayi, M.D., M.Phil.; Asaf Bitton, M.D., M.P.H.
JAMA, September 8, 2020

In 2019, US clinicians began to be rewarded or penalized up to 4% of revenue under the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System (MIPS). Clinicians can choose measures for evaluation from 3 categories: quality, meaningful use, and improvement activities.

The reports in this issue of JAMA by Johnston et al and by Khullar et al evaluated the MIPS performance scores of clinicians and the potential financial implications associated with the MIPS program. The authors found meaningful advantages for clinicians associated with health care systems and among those who treated fewer patients with low socioeconomic status and complex medical needs.

The findings of these studies have important implications for MIPS specifically, and broadly for payment reform. This compelling evidence supports the notion that system-affiliated practices are more likely to be rewarded by pay-for-performance programs than independent practices. However, a large amount of skepticism remains about whether this pay-for-performance approach correlates with better patient outcomes. The proportion of physicians employed by hospitals or health systems has been rapidly increasing from about 28% of primary care physicians in 2010 to almost 50% in 2018.3,4 There are consequences from this consolidation, such as increasing prices in commercial markets without meaningful improvements in care quality and patient outcomes.5 In addition, choice in referrals to inpatient settings, specialty physicians and centers, or ancillary services may be limited.

Because the quality measures were chosen by practices and were process based, the investigators could not disentangle whether their results represent better quality of patient care or reflect resources available to support selection and reporting of quality measures.

The second major finding raised by these reports is the uncomfortable recognition that the MIPS and other alternative payment models consistently appear to penalize physicians who care for low-income and vulnerable populations. Khullar et al used dual eligibility status as a proxy for social, medical, and behavioral health complexity in the Medicare population. This population requires complex medical care, behavioral health services, and long-term supports, all of which must be coordinated to achieve outcome improvements. Dually eligible beneficiaries are approximately 3 times as likely to have significant limitations in activities of daily living than non–dually eligible beneficiaries (30% vs 9%, respectively) and to experience serious mental illness (30% vs 11%). Dually eligible beneficiaries are also twice as likely (48% vs 21%) to belong to racial or ethnic minority groups than non–dually eligible beneficiaries, reflecting the complex interplay between race, geographic location, racism, poverty, and poor health outcomes.

Physicians and other health care professionals who provide care for large proportions of dually eligible beneficiaries must engage in a number of complex, costly activities to improve patient health. Consequently, primary care clinicians who serve medically and socially complex populations have greater process and operational challenges (and clinical difficulties) in providing quality and accessible care to dually eligible populations.

Yet instead of adjusting reimbursement to reflect the differential cost of caring for these populations, it appears that the MIPS may further disadvantage safety net clinicians who provide care for dually eligible beneficiaries. The results reported by Khullar et al are consistent with prior research that demonstrated value-based payment programs disproportionately penalize clinicians and practices that serve low-income patients and reflect design flaws of the payment system.

The Medicare Payment Advisory Commission has recommended replacing the MIPS because it is unlikely to help beneficiaries choose clinicians, help clinicians improve value, or help the Centers for Medicare & Medicaid Services reward clinicians for value. Rewarding improved performance is a laudable policy goal. Programs like the MIPS, however, appear to be disproportionately rewarding well-off health systems while penalizing smaller practices and those serving disadvantaged populations.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D. 

One of the papers says, “Longer-term studies are needed to examine this program as future years of data become available.” Don’t they always say that?

Once more, MIPS does not work, and it has to go. No more studies, please! We already have a proven model that will work for all of us: single payer improved Medicare for All. When the next Congress convenes and the new administration is installed, our roar has to be deafening and unrelenting.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Michael Geruso, Timothy J. Layton, Jacob Wallace
National Bureau of Economic Research, August 2020

Abstract

Exploiting random assignment of Medicaid beneficiaries to managed care plans, we identify plan-specific effects on healthcare utilization. Auto-assignment to the lowest-spending plan generates 30% lower spending than if the same enrollee were assigned to the highest-spending plan, despite identical cost-sharing. Effects via quantities, rather than differences in negotiated prices, explain these patterns. Rather than reducing “wasteful” spending, low-spending plans cause broad reductions in the use of medical services—including low-cost, high-value care—and worsen beneficiary satisfaction and health. Supply side tools circumvent the classic trade-off between financial risk protection and moral hazard, but give rise instead to a cost/quality trade-off.

From the Introduction

Regulated competition between private health plans is becoming the dominant form of social health insurance in the United States. In 2017, 54 million Medicaid beneficiaries (69%) and 19 million Medicare beneficiaries (33%) were enrolled in a private managed care plan. In the same year, almost $500 billion of the $1.3 trillion spent on public health insurance programs went to private managed care plans.

In this paper, we identify the causal effects of the health plan in which a beneficiary enrolls on her healthcare utilization, the quality of care received, and proxies for satisfaction and health. The context of our analysis is Medicaid Managed Care (MMC), the privatized system through which most Medicaid beneficiaries receive benefits today.

In our setting, all plans are required to provide care at zero marginal cost to beneficiaries. It is therefore an ideal context for studying whether various non-cost-sharing plan features (e.g., networks, negotiated provider rates, patient follow-up and medication adherence programs, etc.) can constrain healthcare spending. In contrast, nearly all of the prior econometric literature studying how health plans affect utilization and health outcomes has focused on consumer cost-sharing provisions like copays, coinsurance, and deductibles. But a modern health plan is more than a set of consumer-facing prices, and our analysis sheds new light on the range of impacts generated by supply-side (non-cost-sharing) plan features. To facilitate a transparent comparison between our results and results from cost-sharing studies including the RAND Health Insurance Experiment (Manning et al., 1987) and more recent quasi-experimental work (Brot-Goldberg et al., 2017), we focus our analysis on the types of outcomes that have been the focus of this prior literature. These include overall service utilization and spending, utilization of high- and low-value care, conventional measures of healthcare quality, and surrogate health outcomes like avoidable hospitalizations.

As our first main result, we document statistically and economically significant causal variation in spending across plans. If an individual enrolls in the lowest-spending plan in the market she will generate about 30% less in healthcare spending than if the same individual enrolled in the highest-spending plan in the market. We show that risk-adjusted observational measures and causal estimates of plan spending effects are correlated, but find that the risk-adjusted measures tend to overstate causal differences in spending across plans. Plans that attract healthier patients thus do more to constrain spending—i.e., provide less care—consistent with a classic adverse selection model, where sicker individuals select plans providing more care. This fact has important implications for the use of observational measures of spending and quality as a basis for regulatory rewards or penalties.

After establishing important differences between risk-adjusted (OLS) plan spending effects and causal (IV) estimates, we investigate which factors drive the bottom-line causal differences. First, we find that almost all services are marginal. That is, lower spending plans tend to provide less of nearly everything. This includes inpatient and outpatient visits, primary care physician office visits, and high-value/cost effective drugs. Second, unlike in other markets, differences in provider prices do not explain the differences in healthcare spending across plans in our setting. In a decomposition, prices account for very little of the cross-plan spending differences.

Instead, spending differs because enrollees in low-spending plans use less care, with much of the utilization gap driven by the extensive margin. Importantly (and similar to the effects of deductibles in Brot-Goldberg et al., 2017), utilization reductions do not seem to focus on “low-value” care or “waste”: We estimate that low-spending plans reduce utilization of high-value drugs used to treat diabetes, asthma, and severe mental illnesses, as well as high-value screenings for diabetes, cancer, and sexually transmitted infections.

Finally, we show that the low-spending plans also increase avoidable hospitalizations and decrease consumer satisfaction, as measured by the propensity of auto-assigned enrollees to switch out of their plan post-assignment. These results suggest a clear trade-off between spending and beneficiary satisfaction and health.

We show that there is substantial causal heterogeneity across plans in spending and utilization that arises without any differences in consumer cost-sharing exposure.

Our findings complement a large literature extending back to the RAND health insurance experiment (Manning et al., 1987) that documents how consumer prices impact healthcare utilization. In RAND, and the studies that have followed, patient cost-sharing has proven to be a blunt instrument, affecting the use of low- and high-value services alike (Brot-Goldberg et al., 2017). These findings sparked interest in whether managed care tools offer a scalpel that can target inefficient spending and better manage the high-cost patients responsible for the majority of spending. But our results, along with prior work studying managed care in Medicare (Curto et al., 2017), indicate that supply-side tools exhibit many of the same features and limitations as demand-side tools. Their impacts on healthcare spending are blunt. They indiscriminately reduce utilization, limiting both high- and low-value care rather than targeting “waste.” In another similarity to the effects of consumer cost sharing (as found in Brot-Goldberg et al., 2017), lower-spending managed care plans in our setting do not appear to generate savings by steering patients to lower-cost providers or lowering negotiated prices.

Lastly, our work highlights how supply side tools can achieve spending reductions while circumventing the classic trade-off between financial risk protection and moral hazard noted by Zeckhauser (1970) and Pauly (1974). The spread of plan effects we estimate are similar to the utilization difference between the 0% and 95% coinsurance rate treatment arms in the RAND HIE. Thus, significantly constraining healthcare spending need not require exposing consumers to out of pocket spending. But there is no “free lunch” here, as we also document that these spending reductions come at the cost of beneficiary satisfaction and, ultimately, health.

Conclusion

Our results are important for understanding the potential for managed care to constrain healthcare spending growth. We show that the baskets of rationing devices implicit in managed care can have spending and utilization impacts significantly larger than what could be accomplished by exposing consumers to high deductibles and reasonable coinsurance and copays.

Importantly, rationing via managed care reduces spending without exposing consumers to financial risk, circumventing the classic trade-off between financial risk protection and moral hazard noted by Zeckhauser (1970) and Pauly (1974). These findings are particularly relevant for public insurance programs—including the low-income segments of HIX Marketplaces and Medicare—where policymakers have been reluctant to expose low-income consumers to financial risk.

However, these spending reductions appear to come with a utility cost. Willingness to remain enrolled in a plan is negatively related to that plan’s cost savings. And cost reductions are blunt—reducing utilization of all types of care, lowering traditional measures of healthcare quality, and increasing the likelihood of adverse health events.

https://www.nber.org...

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Comment:

By Don McCanne, M.D.

Medicaid managed care plans have become very popular in states for the obvious reason that they reduce spending. This paper is important because it reveals how the cost savings are achieved.

Most Medicaid programs do not use cost sharing and thus they do not reduce spending that way, but, even if they did, these authors state that “managed care can have spending and utilization impacts significantly larger than what could be accomplished by exposing consumers to high deductibles and reasonable coinsurance and copays.” They also find that differences in provider prices do not explain the differences in health care spending across plans in this setting.

So how does managed care control spending? The plans consider all services to be marginal and thus they reduce utilization of all services regardless of the value of those services. “Lower spending plans tend to provide less of nearly everything. This includes inpatient and outpatient visits, primary care physician office visits, and high-value/cost effective drugs.”

This gives rise to cost/quality trade-offs. Reduction in beneficial health care services obviously reduces the quality of care. Low-spending plans increase avoidable hospitalizations. This cavalier attitude does not go without notice; beneficiary satisfaction is diminished.

How many more studies do we need? The private insurance industry has to go. And, yes, we have a replacement: single payer improved Medicare for All.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Phil Galewitz and Kaiser Health News
Fortune, September 6, 2020

New Mexico Health Connections’ decision to close at year’s end will leave just three of the 23 nonprofit health insurance co-ops that sprung from the Affordable Care Act.

Lauded as a way to boost competition among insurers and hold down prices on the Obamacare exchanges, the co-ops had more than 1 million people enrolled in 26 states at their peak in 2015. Today, they cover about 128,000 people, just 1% of the 11 million Obamacare enrollees who get coverage through the exchanges.

The nonprofit organizations were a last-minute addition to the 2010 health law to satisfy Democratic lawmakers who had failed to secure a public option health plan — one set up and run by the government — on the marketplaces. Congress provided $2 billion in startup loans. But nearly all the co-ops struggled to compete with established carriers, which already had more money and recognized brands.

https://fortune.com…

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CO-OP Health Plans under the Affordable Care Act

From the Comment by Don McCanne, M.D.
PNHP, Quote of the Day, July 2011

The proposed rule has now been released for the establishment of CO-OPs under the Affordable Care Act. The CO-OPs are private, nonprofit organizations that sell insurance, like HMOs and PPOs, under the same rules as the other private insurers.

These are new organizations, and, as such, require a new infusion of capital to meet the reserve requirements for future claims.

Private, for-profit insurers have the capability of establishing start-up costs and solvency reserves by selling shares of stock. Since the CO-OPs are nonprofit, they don’t have this resource to tap. Recognizing this, the Affordable Care Act included provisions for government loans for start-up costs and other loans for solvency (reserve funds for future claims). It is important to understand that these are not grants but are loans that must be repaid, with interest, within five years for start-up loans and fifteen years for solvency loans.

Think about that. The CO-OPs are required to compete with the private insurers under the same terms, while having the additional requirement of paying back these loans. Since their only revenue source is premiums for the insurance they are selling, these loan costs that their competitors don’t have will have to be recovered through higher premiums. Under these terms, how could they possibly compete with the private insurers?

There are many other issues. How long would it take to establish a critical threshold of enrolling enough members to create a viable entity? Since it is likely that the CO-OPs would be subject to adverse selection (enrolling a larger share of patients with greater health care needs), there would be further upward pressure on their premiums (death spiral) since current risk adjustment tools do not recover the full excess losses (as if health care is a “loss”).

It’s too bad. CO-OPs should have offered us the opportunity to establish altruistic health care organizations. Instead, the politicians bent over backwards not only to keep the government out of these programs, but also to protect the private insurers’ marketplace by being sure that the CO-OPs were not allowed a fair playing field by saddling them with insurmountable debt.

We needed a seat at the table.

https://pnhp.org…

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There is very little difference between the co-ops and the “public option”

By Kip Sullivan, J.D.
PNHP, September 29, 2009

Advocates of a “public option” have been extremely critical of the health insurance cooperatives proposed by Sen. Kent Conrad last June and incorporated in the draft legislation released by Senate Finance Committee Chairman Max Baucus on September 16 (2009). “Option” advocates claim the co-ops either will not survive or will be so small they will be unable to force the insurance industry to lower its premiums. This is legitimate criticism.

But “option” advocates should level the same criticism against the “option.” The “option” is no more likely to survive and thrive than the co-op program. A comparison of the legislation that would create “option” programs with the provisions in the Baucus bill that would create co-ops indicates there is only one reason to be less pessimistic about the “option,” namely, the “option” legislation requires that someone (the Secretary of the Department of Health and Human Services) attempt to get the “option” program going. There is no similar requirement for the co-op program.

Rockefeller, Dean, Hacker and their colleagues in the “option” movement are doing a great job of leveling legitimate criticism against the co-op proposal. Their criticisms are aimed squarely at the question of how the co-ops will get started and whether they will ever grow large enough to take substantial market share away from the insurance industry. But they adamantly refuse to level the same criticism at the “option.” They should tell us why. I doubt they will do that. I doubt it because there is no rational explanation for this double standard. And no one likes to admit to behaving irrationally.

https://pnhp.org…

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Comment:

By Don McCanne, M.D.

The CO-OPs were only one of the multitude of defects in the Affordable care Act that we pointed out before it was enacted (and continuously since). As we stated nearly a decade ago, the CO-OPs were doomed from the beginning. Although some in the policy community had insisted that we could still make them work, the fact that only 128,000 individuals in the entire nation are insured by these programs is confirmation that they were and are an abject failure.

Since the two major presidential candidates both oppose single payer Medicare for All, the only substantial policy proposal, beyond tweaking, that remains under consideration is the public option – a version of Medicare that competes in the marketplace with private insurance plans. Much has been written about the inadequacies of such a proposal, but this is not new. Kip Sullivan warned us a decade ago that from a policy perspective, there was very little difference between the CO-OPs and the public option. Although there are many variables in design that might be considered as legislation is drafted, there is absolutely no question that the public option will not lead to a universal, single payer model of Medicare for All, as some in the policy community would hope.

In 2016, a resolution was introduced in the Senate calling for building on the Affordable Care Act by the addition of a public health insurance option. My comment at that time (2016):

This week an intensive campaign is being initiated in support of a “public option” – offering the choice of a public, nonprofit insurance plan which competes with private health plans. Our enthusiasm should be tempered.

Following are a couple of points to keep in mind, especially when you hear promises that the public option is a giant step towards single payer: 

• A public option will be only one more player in our costly, fragmented system of funding health care. It alone will bring us none of the important features of a single payer system such as efficiency, equity, systemic cost savings, and universality. The profoundly wasteful administrative complexity will remain.
• Previous efforts by Congress, heavily influenced by the insurance industry, to design a public option led to a highly flawed model that would prevent the “unfair” competitive advantage that a government program would otherwise have over the private insurance industry. This same insurance industry influence is precisely why the co-op models authorized by ACA are now failing. And there is absolutely no reason to believe that the insurance industry might change its tune now.
• The public option has been characterized as a Medicare buy-in. But Medicare is an equitably funded social insurance program covering everyone who is eligible, whereas the public option would be just another individual plan in a market of private plans, likely with higher premiums because of adverse selection.
• If a public option were to be enacted some believe that it would be only a matter of time before everyone would want in once it demonstrates its superiority, and then we would have a de facto single payer system. You need look only at the experience with the conspiracy between Congress and the private insurance industry in the establishment of the private Medicare Advantage plans that compete with traditional Medicare. Congress has given the private plans an unfair advantage so Medicare beneficiaries are moving from the public program to the private plans in ever greater numbers – the exact opposite of what the public option supporters visualize.
• The Affordable Care Act drew support of much of the progressive community as it seemed to them to be the only politically feasible approach at the time. Thus the clamor for comprehensive reform died down. We are hearing again that single payer is not feasible, but the public option is. When the public option is enacted, it will be mislabeled as single payer, and then it will be exposed for the miserable failure that it will be because it was designed by the private insurance industry to fail (like the co-ops). The single payer concept will have been tarnished, and it could be decades before our nation would recover and be ready for reform that really works. In the meantime, millions would have gone broke, suffered, and died merely because we didn’t think single payer was feasible.

Many look to Jacob Hacker for inspiration on enacting and implementing a public option. But he has identified the greatest barrier to moving forward. In a recent Vox article, he wrote, “Private plans lobbied aggressively against the public option in 2009 on the grounds that it would amount to unfair competition. But insurers don’t want a level playing field; they want the field tilted in their favor.”

Now see if you can find a Congress that doesn’t tilt the field in favor of the private insurers. Not even on the horizon.

https://pnhp.org…

Do not let up in your advocacy for the single payer model of an improved Medicare for All.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

Senator Elizabeth Warren, Congresswoman Ayanna Pressley, Congresswoman Barbara Lee, September 3, 2020

The Anti-Racism in Public Health Act would create a Center on Anti-Racism in Health at the CDC, improving the federal government’s ability to develop anti-racist health policy; Bill would also create a Law Enforcement Violence Prevention Program at the CDC

Washington, DC — United States Senator Elizabeth Warren (D-Mass.) and Representatives Ayanna Pressley (D-Mass.) and Barbara Lee (D-Calif.) today announced their bicameral bill to confront the public health impacts of structural racism through two bold new programs within the Centers for Disease Control and Prevention (CDC). Senators Mazie K. Hirono (D-Hawaii), Edward J. Markey (D-Mass.), Jeff Merkley (D-Ore.), and Tina Smith (D-Minn.) are all cosponsors of the Senate bill.

The COVID-19 pandemic has made it impossible to ignore how centuries of structural racism have created deep disparities in health outcomes for Black and Brown communities: Black and Brown people are nearly three times more likely than white people to contract COVID-19 and one to two times more likely to die from the disease. People of color are also disproportionately affected by chronic health conditions such as diabetes, asthma, hepatitis, and hypertension; infant mortality; maternal mortality and morbidity; and police brutality — and also less likely to be insured and have access to health care providers.

The federal government’s failure to adequately collect race and ethnicity data on COVID-19 testing, hospitalization, and deaths has also demonstrated why comprehensive research is needed to study the health impacts of structural racism and to develop race-conscious public health approaches and reverse disparities that have plagued our nation for too long.

To help expand research and investment into the public health impacts of structural racism, as well as to require the federal government to begin actively developing anti-racist health policy, Senator Warren, Congresswoman Pressley, and Congresswoman Lee have introduced the Anti-Racism in Public Health Act, which would:

• Create a “National Center for Anti-Racism” at the Centers for Disease Control and Prevention (CDC) to declare racism as the public health crisis that it is and further develop the research base and knowledge in the science and practice of anti-racism. The Center would undertake such activities as:
• Conducting research, collecting data, awarding grants, and providing leadership and coordination on the science and practice of anti-racism in the provision of health care, the public health impacts of systemic racism, and the effectiveness of interventions to address these impacts.
• Creating at least three regional centers of excellence in anti-racism.
• Educating the public on the public health impacts of structural racism and anti-racist public health interventions.
• Consulting with other Centers at the CDC to ensure that scientific and programmatic activities initiated by the agency consider structural racism in their designs, conceptualizations, and executions.
• Create a Law Enforcement Violence Prevention Program within the National Center for Injury Prevention and Control at the CDC. Physical and psychological violence perpetuated by law enforcement results in deaths, injuries, trauma, and stress, and disproportionately affects marginalized populations. This bill would take a public health approach to combating police brutality and violence by creating a dedicated law enforcement violence prevention program at the CDC.

“It is time we start treating structural racism like we would treat any other public health problem or disease: investing in research into its symptoms and causes and finding ways to mitigate its effects,” said Senator Warren. “My bill with Representatives Lee and Pressley is a first step to create anti-racist federal health policy that studies and addresses disparities in health outcomes at their roots.”

“For far too long, our federal government has failed to recognize and address the structural racism that has devastated Black and brown communities and denied access to quality health care,” said Congresswoman Pressley. “With the COVID-19 pandemic unveiling and exacerbating racial disparities in health outcomes, it is time we recognize and treat structural racism and police brutality as the public health crises that they are. This first-of-its-kind bill would expand federal research and investment into the public health impacts of structural racism, require the federal government to proactively develop anti-racist health policy, and take a public health approach to combatting police violence. We must have a coordinated public health response to structural racism, and this bill would do just that.”

“COVID-19 has exposed the injustices in health outcomes for Black and Brown people, and it’s no coincidence,” said Rep. Barbara Lee. “In addition to addressing the lasting impacts of systemic racism in criminal justice, economic inequality and the like, we must also commit resources to understanding racially unjust health outcomes. I’m taking steps, alongside Congresswoman Pressley and Senator Warren, toward reversing racism in our health care system with this legislation.”

“Since the advent of modern medicine, people of color have suffered from disparities in the care they receive and the health outcomes we see,” said Senator Markey. “With this legislation, we recognize that combatting racism is a public health necessity. I am honored to work with Representatives Pressley and Lee and with Senator Warren in advancing this important legislation.”

“Everyone deserves affordable, quality health care, but it’s not enough to just work for better health care for all-we need to also acknowledge and directly address the unacceptable racist disparities in health care,” said Senator Merkley. “The coronavirus has put those inequities on full display, and has further emphasized that living in a racist society is a pre-existing condition for too many people of color. Black and Brown Americans get less quality care, have worse health outcomes regardless of their incomes or other factors, and are regularly sicker because of systemic racism that has long shaped society and public health. It’s time to pass immediate reform to change that.”

“Communities of color like the Pacific Islander community in Hawaii have acutely suffered during the coronavirus pandemic, said Senator Hirono. “The federal government must take bold action to create anti-racist federal health policy, and this bill takes critical steps to study and address racial disparities in public health and safety.”

The bill is endorsed by the following organizations:

Center for Policing Equity; Center for Popular Democracy; Center for Reproductive Rights; Center for the Study of Racism, Social Justice & Health at UCLA; Hispanic Federation; The Justice Collaborative; Justice in Aging; The Lawyer’s Committee; The Leadership Conference on Civil and Human Rights; National Medical Association; National Partnership for Women & Families; NAACP; National Urban League; Physicians for a National Health Program (PNHP); PolicyLink; Poverty & Race Research Action Council (PRRAC); Public Citizen; Social Security Works; UCLA’s COVID-19 Task Force on Racism and Equity; UnidosUS; Union for Reform Judaism; We Must Count Coalition.

https://www.warren.senate.gov…

https://pressley.house.gov…

https://lee.house.gov…

“Anti-Racism in Public Health Act of 2020” (15 pages):
https://www.warren.senate.gov…

“Anti-Racism in Public Health Act of 2020” (one page summary):
https://www.warren.senate.gov…

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Comment:

By Don McCanne, M.D.

This is a good start. Let’s do it.

Physicians for a National Health Program (PNHP) has endorsed this legislation.

Stay informed! Visit www.pnhp.org/qotd to sign up for daily email updates.

By Alexandra Power-Hays, M.D. and Patrick T. McGann, M.D.
The New England Journal of Medicine, September 1, 2020

The merciless killing of George Floyd by Minneapolis police officer Derek Chauvin and the more recent shooting of Jacob Blake by Kenosha police officer Rusten Sheskey have catalyzed the most widespread protests in American history, calling not only for an end to police brutality but also for a nation in pain to reflect on the layers of racism that allow such brutality to persist. Medicine is a mirror for the racial injustice in our society; it is a field riddled with racial disparities in everything from research funding to patient care to life expectancy. There may be no population of patients whose health care and outcomes are more affected by racism than those with sickle cell disease (SCD). Patients with SCD are too often marginalized and dismissed while seeking medical care when their bodies hurt and they cannot breathe. As medical leaders around the United States issue statements denouncing racial injustice and calling for us to “dismantle racism at every level,” we must ensure that these pledges translate into durable improvements for patients with SCD.

Unfortunately, the social construct of race in America requires the majority of patients with SCD not only to face the consequences of a serious health condition, but also to navigate a society in which the color of their skin is often an unfair disadvantage.

“Structural racism” refers to the system of discriminatory policies that assign privilege and power on the basis of race. For example, the legacy of redlining, a policy that allowed banks to deny mortgages to Black Americans who wanted to purchase homes in White-designated neighborhoods, persists today in the form of high rates of housing insecurity among Black Americans, including those with SCD. These racist policies have led to enduring cycles of poverty that result in food insecurity, fewer employment opportunities, and inconsistent health insurance coverage, all of which compound the challenges faced by people living with SCD.

United action against racism’s impact on the health of patients with SCD is long overdue. The most recent senseless murders of Black Americans and the subsequent wave of pledges to dismantle racism should be our call to action. Change begins with a conversation, but words are not sufficient; we must take action to make enduring improvements in the care of patients with SCD. In the box, we offer a framework and suggestions for initiating change. The current generation of patients with SCD should be allowed to lead full and healthy lives without fear or distrust of the health care institutions whose purpose should be to protect and serve.

https://www.nejm.org…

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Comment:

By Don McCanne, M.D.

How many of us have buried in our subconsciousness the concept – a concept that we have not even bothered to formulate in words – that structural racism is a scourge that dictates that those who perpetrate it should reform their ways as a step towards creating a more just society for all? Oops. Isn’t this very attitude part of the infrastructure that supports structural racism? Sort of like responding to “Black Lives Matter” with “Well, white lives matter too.”

The New England Journal of Medicine has made the full article excerpted above available to all for free – perhaps sort of their version of instructing others to address the scourge of structural racism. In the excerpt is mentioned a box that is also included at the link above which offers a framework and suggestions for initiating change in our attitudes toward and management of not sickle cell disease itself, but the racism associated with sickle cell disease. Hopefully this would serve in opening a door to enlightenment on this topic that has been suppressed and neglected throughout the history of our nation.

Too busy to read the full article? Clairvoyant enough to recognize that you are free of even the slightest taint of racism? How fortunate you are.

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The U.S. could learn a lot from Britain.

By Ezekiel J. Emanuel, Cathy Zhang and Amaya Diana
The New York Times, September 1, 2020

Americans and American biomedical researchers have often prided themselves on conducting the best clinical research in the world. Yet with over six million coronavirus cases and 183,000 deaths, the United States has produced little pathbreaking clinical research on treatments to reduce cases, hospitalizations and deaths. Even one of the most important U.S. studies to date, which showed that the antiviral drug remdesivir could reduce the time Covid-19 patients spent in the hospital to 11 days from about 15, had too few subjects to demonstrate a statistically significant reduction in mortality.

Progress on therapeutics research has been a very different story in Britain. In mid-March researchers there began a randomized evaluation of Covid-19 therapies, known as Recovery, that involves every hospital in the nation. The goal was to conduct large, rapid and simple randomized trials to define standard treatment. Some 12,000 patients were quickly randomized — that is, assigned by chance to receive different treatments — and within 100 days of the effort’s start, researchers made three major discoveries that transformed Covid-19 care worldwide.

Researchers found no benefits from the use of hydroxychloroquine in hospitalized Covid-19 patients, nor from the lopinavir-ritonavir drug combination. On the other hand, dexamethasone, an inexpensive steroid, was found to reduce mortality by up to one-third in hospitalized patients with severe respiratory complications. Each of these results was conclusive and went against the expectations of many clinicians, guideline writers and lay advocates. The results demonstrated the critical need for randomized trials to separate drugs we hope work from treatments we know work.

In the United States, by comparison, the government-sponsored Patient-Centered Outcomes Research Institute has spent millions of dollars creating a large clinical research network but has produced no research results on Covid-19 therapeutics.

As the United States designs research protocols to investigate clinical therapeutics, we should ask: What has gone right in Britain that the United States can adopt to help rapidly and definitively identify Covid-19 therapeutics that really work, and just as important, those that don’t?

Maybe the most important factor is an attitudinal difference: British clinical researchers have a longstanding commitment to large, simple and rapid randomized trials. American researchers prefer smaller, selective and complex trials with many restrictions on patients who can enroll.

First, the Recovery trials are designed to be easy to take part in, with paperwork that is short and simple.

Second, the Recovery protocol was quickly approved at the national level and adopted by all hospitals in Britain.

Third, background patient data provided by the National Health Service helped to simplify the research process.

Fourth, support from leaders in government health care ensured widespread cooperation by hospitals.

Fifth, Britain has a national system of research nurses who were rapidly redeployed to work on Covid-19 research.

And last, the British effort was incorporated as part of everyday clinical care in hospitals. The alternative, of haphazardly trying anything and everything, which seems to have been the American way, was rejected in Britain because it neither optimizes patient care nor generates useful data.

An additional feature worth noting about the Recovery effort is that it has been relatively inexpensive to conduct.

Unfortunately, unlike Britain, the United States has lacked a clear, unified message from government health care leaders, major insurance companies and hospital systems to put in place large, simple randomized trials that are considered the standard of care for Covid-19 treatment. We need to change that muddled approach now and reassert the nation’s clinical research excellence.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

The United States spends the most money on health care, yet we have failed to prevent the expansion of the Covid-19 pandemic and the deaths that have resulted. Although we should be leading the world in the urgent research needed to treat and prevent the spread of this disease, our progress, when compared to that of Britain, has been worse than disappointing.

Ezekiel Emanuel and his coauthors suggest that we could learn from Britain, and they list features that we should consider to improve our efforts. However, in their list, they may have missed the forest for the trees.

Britain has a public health system whereas ours is largely private even if heavily subsidized with public funds. Their system is designed to serve patients whereas our system is designed on a business model. That applies to research as well. Their research again is predominantly designed to serve patients whereas our research is designed to corner markets with leveraged high prices. Thus Britain’s research is coordinated whereas ours is fragmented into sectors that are competing to get the earliest control of the largest and most expensive sectors of the market. In health care, Britain shows us that cooperation is the key to success whereas, in our devotion to the false promise of competition, we continue to show that we drive prices up, not down, while leaving tens of millions without adequate care.

We may not be ready to nationalize our health care delivery system but at least we could socialize our insurance through the single payer model of an improved Medicare for All. With public funds administered through a public financing system, we could make better use of our NIH, CDC and even the WHO. If we had responsible public stewards who supported solidarity and cooperation, we would be much further along in our recovery from this pandemic.

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By Catalina Amuedo-Dorantes, Neeraj Kaushal, Ashley N. Muchow
National Bureau of Economic Research, August 2020

Abstract

Using county-level data on COVID-19 mortality and infections, along with county-level information on the adoption of non-pharmaceutical interventions (NPIs) in the United States, we examine how the speed of NPI adoption affected COVID-19 mortality. Our estimates suggest that advancing the date of NPI adoption by one day lowers the COVID-19 death rate by 2.4 percent. This finding proves robust to alternative measures of NPI adoption speed, model specifications that control for testing and mobility, and across various samples: national, restricted to the Northeast region, excluding New York, and excluding the Northeast region. We also find that the adoption speed of NPIs is associated with lower infections, as well as lower non-COVID mortality, suggesting that these measures slowed contagion and the pace at which the healthcare system might have been overburdened by the pandemic. Finally, NPI adoption speed appears to have been less relevant in Republican counties, suggesting that political ideology might have compromised their efficiency.

From the Introduction

In the United States, where COVID-19 has taken a high toll in terms of infections and mortality, skepticism toward NPIs reigns high among the public and legislators. Early in the pandemic, President Trump famously criticized NPIs by remarking that “the cure cannot be worse than the problem itself.” The nation remained divided on the effectiveness of NPIs, even as the pandemic raged from March to early May 2020 in the northeast, spreading to the rest of the country thereafter. Surveys show that conservative Republicans expressed more skepticism about NPIs than liberal Democrats. State and local implementation and lifting of NPIs were often driven by political ideology. Republican-governed cities were slower in adopting NPIs, whereas cities led by Democrats were more aggressive.

Heterogeneous impacts

Studies show that attitudes towards the efficacy of NPIs have been partisan, with Republican governors and mayors being more reluctant to implement NPIs. It is also possible that residents in majority-Republican counties with NPIs in place may be less compliant with health care guidelines and recommendations. We first examine the differential impact that the speed of NPI adoption had in Republican counties—measured as those with a Republican vote share above 50 percent in the 2016 presidential election—given the role of political partisan ideology in NPI adoption. Adopting an NPI one day earlier lowers COVID-19 mortality in majority-Republican counties by approximately 2.4 percent, whereas the reduction in other counties reaches 5.4 percent. In other words, speeding up the implementation of NPIs in primarily Republican counties would lower COVID-19 mortality by half the amount it would in non-Republican counties. Why? Perhaps, NPIs are less strictly observed in Republican counties, in which case, speeding up their implementation does not have the same bite as in other counties. Note that descriptive statistics in Table 1 show that, according to our NPI speed measure, Republican counties were more likely to be early adopters, largely on account of the late outbreak of the pandemic in these counties. Thus, our findings suggest that, despite the advantage of learning from the experience of counties where the virus spread earlier, the NPIs were less effective in these counties.

A couple of studies in the United States have investigated the effect of stay-at-home orders on infections and mortality from COVID-19. Both studies find that NPIs are associated with lower infection and mortality rates. We build on this research by assessing the relevance of the adoption timing of two NPIs—safer-at-home orders and non-essential business closures—on mortality.

Summary and Conclusions

The rapid spread of the COVID-19 pandemic took the world by surprise. In the absence of a vaccine, and to halt the devastating impact of the pandemic on lives, several countries opted for the adoption of non-pharmaceutical interventions (NPIs). The United States was no different in that regard, even though the response has been more fragmented and piecemeal. Prior research has shown the effectiveness of NPIs in curtailing deaths in the United States, Europe and Asia. Our focus is on the importance of their timeliness, the mechanisms behind it, and the heterogeneity of any effectiveness depending on the political ideology and degree of vulnerability of counties.

Using county-level data on COVID-19 mortality and infections, along with county-level information on the adoption of stay-at-home orders and business closures, we examine how the adoption speed of NPIs has affected COVID-19 mortality. We find that moving up the implementation date of NPIs by one day lowers the COVID-19 death rate by 2.4 percent. The effectiveness of acting early is similar for both stay-at-home orders and business closures. An event study addresses concerns regarding the endogeneity of NPI adoption, and robustness checks show the results persist when introducing controls for testing and mobility, altering the definition of adoption speed, weighting counties by population size, and considering different geographic scopes. Finally, we confirm how the relevance of responding early stems from the ability to slow contagion, which likely prevented the overburdening of the healthcare system. We also find that NPI adoption speed has less relevance in Republican counties—a possible byproduct of skepticism and reluctance to apply or fully comply with NPIs. In contrast, NPIs appear similarly effective, and their speed of implementation equally as relevant, in counties with distinct degrees of vulnerability to the disease, as captured by an index of comorbidity and the share of residents without health insurance, unemployed, or living in poverty.

While we await anxiously a vaccine or cure, NPIs remain the main mechanism to curtail COVID-19 deaths. Gaining a better understanding of their timeliness and the importance of responding early is essential, especially in the foreseeable occurrence of additional waves.

https://www.nber.org…

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Comment:

By Don McCanne, M.D.

Two non-pharmaceutical interventions (NPIs) used during the Covid-19 pandemic – stay-at-home orders and business closures – were effective in reducing mortality during the pandemic, with effectiveness being greater with earlier implementation of the interventions. This was just as true for counties with greater vulnerability such as those with higher rates of comorbidity and with higher levels of being uninsured, unemployed, or living in poverty.

However, Republican counties were slower to implement NPIs, and the delay was followed by higher mortality rates. The differences were thought to be related to political ideology. It may be not only the delay that increased mortality, but it may also have been due to lower compliance, based both on political ideology prevalent in the community and on Republican politicians who failed to provide the leadership needed in times of a public crisis.

The lesson here should be much more broad than just that of the failures in managing the Covid-19 pandemic. Health policy science is quite advanced, and we know many ways to improve the health of the nation. An example would be implementation of a health care financing system that would ensure access to and affordability of comprehensive health care services for everyone – a single payer, improved Medicare for All. But too many politicians lay the policy science aside and grant a higher priority to anti-government political ideology.

We now have 183,000 Covid deaths in the United States, and many of them could have been prevented with more effective political leadership. If we are going to be able to enact and implement the policies that we know work to benefit the health of all of us, we are simply going to have to change the politics. It’s too late to ask the 183,000 who have died, but with the facts in hand, shouldn’t the rest of us take action?

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Some patients are still receiving staggering bills. Others don’t qualify because conditions other than Covid-19 were their primary diagnosis.

By Abby Goodnough
The New York Times, August 29, 2020

A program Mr. Trump announced this spring… “should alleviate any concern uninsured Americans may have about seeking the coronavirus treatment,” Mr. Trump said in April about the program, which is supposed to cover testing and treatment for uninsured people with Covid-19, using money from the federal coronavirus relief package passed by Congress.

The program has drawn little attention since, but a review by The New York Times of payments made through it, as well as interviews with hospital executives, patients and health policy researchers who have examined the payments, suggest the quickly concocted plan has not lived up to its promise. It has caused confusion at participating hospitals, which in some cases have mistakenly billed patients who should be covered by it. Few patients seem to know the program exists, so they don’t question the charges. And some hospitals and other medical providers have chosen not to participate in the program, which bars them from seeking any payment from patients whose bills they submit to it.

Large numbers of patients have also been disqualified because Covid-19 has to be the primary diagnosis for a case to be covered (unless the patient is pregnant). Since hospitalized Covid patients often have other serious medical conditions, many have other primary diagnoses.

Critics say the stopgap program is among the strongest evidence that Mr. Trump and his party have no vision for improving health coverage, and instead promote piecemeal solutions, even in a national health crisis. Mr. Trump had promised a plan to replace the Affordable Care Act by the beginning of August, but none has been announced and he and other Republicans barely mentioned health policy in their national convention last week.

Unlike previous administrations during public health emergencies, Mr. Trump’s has not encouraged even temporary expansions of Medicaid — except for limited Covid testing — in states where the program covers few poor adults. It also declined to broadly reopen enrollment for Affordable Care Act plans once the pandemic began, although people who lose job-based coverage can enroll.

“This is not the way you deal with uninsured people during a public health emergency,” said Sara Rosenbaum, a professor of health law and policy at George Washington University.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Even though the United States has the most expensive health care system of all, it still leaves tens of millions of individuals uninsured or underinsured. Because of the failure of our government to ensure adequate coverage for all, it became obvious that something was going to have to be done to cover the expenses of the victims of the Covid-19 pandemic without the means to pay for their care. To no surprise, trying to provide emergency patching of an inadequate health care financing infrastructure has fallen far short of the need.

If we had a single payer, improved Medicare for All program already in place, qualifying for health care would not have been an issue. The economic stress caused by the pandemic would still have to be managed, much as with other catastrophic events, but wouldn’t it have been so much better to have a fully functioning health care financing system already in place? Even with additional emergency financing, we are still leaving far too many out of the system. Besides, it would have been less expensive to do it right in the first place. Obviously, we can still fix it so this won’t happen again.

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