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ACO wonks stumbling through the pandemic

ACO wonks stumbling through the pandemic

Maintaining Progress Toward Accountable Care And Payment Reform During A Pandemic, Part 1: Utilization And Financial Impact

By William K. Bleser, Elizabeth Singletary, Hannah L. Crook, Jonathan Gonzalez-Smith, Robert S. Saunders, Mark B. McClellan
Health Affairs Blog, April 14, 2020

The purpose of this two-part Health Affairs Blog post is to summarize impacts, issues, and policy implications due to the coronavirus pandemic for the largest payment reform program in the country: accountable care organizations (ACOs). Clinician organizations participating in, and payers running, payment reform programs face significant uncertainty. ACOs, in particular, face substantial risk of financial loss related to their cost-performance requirements, and decisions to stay in the program or leave are rapidly approaching.

In Part 1 of this post, we estimate coronavirus-related changes in use and financial impact on ACOs based on existing data.

The Bottom Line

All in all, any given ACO’s shared savings and losses for performance year 2020 will depend on how much the utilization increase from COVID-19 is offset by the decrease in procedures and primary care visits. Our estimated ranges indicate a likely scenario of net increased costs, which will vary for any given ACO based on policies in local geographies, the prior health status and COVID-19 prevalence for the attributed population, and the ACO’s own surge policies. The main message is that COVID-19 can have potentially large financial impacts on ACOs and more strongly affect physician-led ACOs. The uncertainty for any given ACO will challenge them in their current pandemic response and, without action, may limit their willingness to remain in ACO programs.

ACOs across the country vary tremendously in size, structure, geography, and patient characteristics, and many ACOs are unlikely to have sufficient liquid cash reserves needed to weather the crisis and tremendous uncertainty without significant supports and flexibilities.

https://www.healthaffairs.org…

Maintaining Progress Toward Accountable Care And Payment Reform During A Pandemic, Part 2: Immediate Issues And Short-Term Actions

Health Affairs Blog, April 15, 2020

In Part 2, this post, we identify immediate issues and short-term actions that private payers, Medicare, and Medicaid can take immediately to adjust their ACO programs to adapt to this crisis in the coming weeks and months.

Conclusions And Summary Of Recommendations

The coronavirus pandemic is perhaps a once-in-a-lifetime health and economic crisis. In addition to broader health outcomes and care delivery impacts, it threatens the progress of payment reform writ-large. The spread of payment reform is quite large to date, with nearly 1,600 ACO contracts across all payers covering almost 44 million lives (about 13 percent of the US population). The MSSP ACO program covers more than 11 million beneficiaries alone. In addition, these payment reforms have provided health care organizations with infrastructure and competencies that they have been able to shift toward community-based population health surveillance and management to limit the impact of the epidemic.

Based on current data, we have found that the COVID-19 pandemic will have significant negative financial impacts on ACOs based on: increased use and expenditures from COVID-19 cases that can lead to smaller shared savings or new shared losses, non-reimbursable infrastructure costs, and reduced revenue in primary care and elective procedures that can cause cash flow problems for smaller and less resourced ACOs. Uncertainty is substantial in all of these cases and can vary tremendously depending on an ACO’s geography, structure, beneficiary health, and size, which can cause anxiety for ACOs considering their future in these payment reform programs. These anxieties could result in ACOs dropping out of the program entirely or consolidating together (which is associated with less competition and decreased value).

We offer suggestions for payers such as CMS and commercial insurers in the short term to help continue progress, including providing reassurance to ACOs and other health care delivery organizations participating in alternative payment models, clarifying telehealth flexibilities and fixes, and harmonizing 1135 waivers with payment reform specifications. In many cases, these reassurances and flexibilities will need to be paired with support for infrastructure development related to new telehealth technology and public health surveillance activities, at least.

We plan to follow this blog post with a subsequent one in the coming weeks on longer-term program considerations and potential solutions such as infrastructure support.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

Earlier this week the National Association of ACOs released the results of a survey indicating that “a large portion of risk-based ACOs are likely to quit over concerns about COVID-19.” Today Mark McClellan and his colleagues at Duke University, proponents of the ACO model of health care financing, explain the impact that the COVID-19 pandemic has had on ACOs, concluding, “The uncertainty for any given ACO will challenge them in their current pandemic response and, without action, may limit their willingness to remain in ACO programs.”

In the past they have released reports indicating that the results of ACOs in achieving higher quality at lower costs have been less than stellar, but they have continued to support the model suggesting that more experience with it may improve the results. If there was ever any doubt that the model is irreparably flawed, the experience under the stress of the pandemic should have laid that doubt to rest.

Yet they do not want to give up. They are suggesting modifications that will surely result in considerable infusion of public funds, but they are doing it to salvage the highly defective ACO model as opposed to improving the lot of patients and their health care professionals when compared with what would be happening under the traditional fee-for-serve Medicare model. Under traditional Medicare, absent the ACOs, essential health care services would be rendered, and Medicare would pay the bills. That’s as it should be.

We all know that Medicare is not perfect, but, instead of playing around with illogical constructs advanced by advocates of the “art” of policy rather than the science of policy (as if process is what is important and the product doesn’t matter), we should enact and implement those changes that will improve Medicare, and then, of course, expand it to cover everyone. Yes, it’s time for single payer Medicare for All. Let’s take care of the patients, not the wonks.

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Tribute to Dr. Beth Potter

From Wisconsin PNHP, Linda and Gene Farley chapter (Madison, Wisc.)
April 15, 2020

On March 31, we lost our dear friend, colleague, and fellow PNHP member, Dr. Beth Potter, and her husband, Robin Carre in a brutal and incomprehensible homicide. In her professional life, Beth devoted herself to serving the most vulnerable in our community with compassionate medical care, educating medical students and residents, and looking after the health of health care workers. She was a powerful advocate for Health Care for All and a longtime member of PNHP.

Dr. Potter was an associate professor in the University of Wisconsin Department of Family Medicine and Community Health, and a brilliant and sympathetic primary care doctor at the Access Community Health Center. She dedicated her career to the health of families, women, and underserved communities. As the Medical Director of Employee Health Services for UW Health, she championed initiatives aimed at fostering the wellness of her health care colleagues.

Beth was a highly respected medical educator. Her work focused on teaching evidence-based medicine, wellness, women’s health, and investigating ways in which emerging technologies can be used to advance medical education. She inspired students, residents, and colleagues with her joyful and empathetic approach to patient care.

She embodied a holistic vision of the community physician, incorporating service to society and advocacy in the mission to improve health for everyone. Beth was a compelling speaker and organizer for single-payer health care and for eliminating the scourge of gun violence.

Our hearts are broken, but in her honor, and for all those she served so well, we encourage everyone to support the work of PNHP.

Dr. Beth Potter in 2015.

Is the American health care system healthy?

By Charles Katzenberg, M.D.
Arizona Daily Star, April 14, 2020

In the April 9 edition of the Arizona Daily Star, Henry Brean wrote about how St. Phillips Episcopal Church is using $35,000 in donations to leverage payment of $3.5 million in medical debt for 1,700 Tucson households. Medical debt is currently the No. 1 cause for bankruptcies in America, affecting over 500,000 families every year. In addition to medical debt, the coronavirus pandemic has stressed multiple parts of our health-care system. Is there a better road we might take?

At present, health insurance for most Americans is tied to employment. In 2018, 58% of non-elderly Americans, about 180 million, received employer-based insurance, according to the Kaiser Family Foundation. In the past three weeks, almost 17 million Americans have lost their jobs and filed for unemployment insurance. This represents 10% of the workforce. Some of these 17 million will lose their employer-based health insurance and some are already uninsured.

In 2018, 9% of Americans, 29.7 million, did not have health insurance. In addition, 13.5%, about 44 million who had insurance, were considered “under-insured” meaning that their out-of-pocket health expenses exceed 5-10% of their income, according to the Commonwealth Fund 2019 state scorecard.

For example, if a family’s annual income was $50,000 and they were forced to spend more than $5,000 (10%) on health insurance and other out-of-pocket health-care costs, this would be considered unreasonably high. So, approximately 74 million Americans either have no health insurance or they are under-insured, i.e. they cannot afford their premiums, deductibles and co-payments.

We know that those who are uninsured and under-insured will tend to avoid coming in for medical evaluation or care because the costs will come right out of their pockets and compromise their ability to pay rent, buy food, clothing, medications or other essentials.

What if every American had cradle-to-grave health insurance that was not tied to employment? You might say, “that would be nice but I don’t think it is affordable and besides, I don’t want to lose my current health insurance.”

However, what if you were able to pay less out of your pocket than you currently do for the same or better health insurance?

You might say that would be nice, but how is that possible?

What if you never had to worry about where your health insurance would come from if you moved or changed jobs or were fired or laid off in a pandemic?

You might say that would be nice, but how is that possible?

What if you had the freedom of choice to see any physician or go to any hospital in the U.S., rather than be limited to whatever local network your health insurance dictates? You might say that would be nice, but that sounds too good to be true.

What if over the next few months you develop a fever, cough and shortness of breath and wonder if you might have COVID-19? If you knew that all costs related to diagnosis, treatment and hospitalization were covered, would you be more likely to come in promptly for testing? You probably would say “yes.”

What if all of the above “what ifs” were part of an American health-care plan? Over the next year you will hear lots of discussion of how we can improve our health-care system to not only be more responsive to a pandemic, but to offer every American affordable and comprehensive health insurance. You might hear the term Medicare for All.

Check it out, kick the tires and see if it might make sense to you. What we currently have could be called health care for some while millions are left on the sidelines.

Dr. Charles Katzenberg is a cardiologist who retired from Banner University Medical Center in 2019.

https://tucson.com…

Financial Times on the social contract

Virus lays bare the frailty of the social contract

Radical reforms are required to forge a society that will work for all

By The Editorial Board
Financial Times, April 3, 2020

Beyond defeating the disease, the great test all countries will soon face is whether current feelings of common purpose will shape society after the crisis. As western leaders learnt in the Great Depression, and after the second world war, to demand collective sacrifice you must offer a social contract that benefits everyone.

Radical reforms — reversing the prevailing policy direction of the last four decades — will need to be put on the table. Governments will have to accept a more active role in the economy. They must see public services as investments rather than liabilities, and look for ways to make labour markets less insecure. Redistribution will again be on the agenda; the privileges of the elderly and wealthy in question. Policies until recently considered eccentric, such as basic income and wealth taxes, will have to be in the mix.

https://www.ft.com…

Comment:

By Don McCanne, M.D.

It has become obvious to many of us that the government must play a greater role in establishing policies that allow us to advance a social contract that benefits everyone. The significance of today’s Quote of the Day is that it comes from the editorial board of The Financial Times, a publication that supports economic liberalism — a political and economic philosophy based on strong support for a market economy and private property in the means of production.

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COVID-19: The swan song of ACOs

More than half of risk-bearing ACOs may leave Medicare shared savings program

By Maria Castellucci
Modern Healthcare, April 13, 2020

Most accountable care organizations taking on downside risk in the Medicare Shared Savings Program are considering dropping out due to concerns they will suffer financial losses in response to the COVID-19 pandemic, according to a new survey.

Fifty-six percent of risk-bearing ACOs said in a survey from the National Association of ACOs that they were very or somewhat likely to drop out of the Medicare program by May 31, which is the deadline the CMS offers to quit the program without being on the hook for losses. The survey had 81 participants, representing 42% of the program’s risk-bearing ACOs.

The COVID-19 pandemic is causing concern among ACOs that they’ll incur penalties this performance year because routine, preventive care has been put on hold while at the same time healthcare costs are rising through more hospitalizations.

“When ACOs made a commitment to assume risk, they didn’t expect they’d be handling the risk of a global pandemic,” said Clif Gaus, CEO of NAACOS, in a prepared statement.

https://www.modernhealthcare.com…

Survey Shows ACOs’ Concerns About the Effect of COVID-19

National Association of ACOs

In addition to the significant toll the COVID-19 pandemic is having on our healthcare and economic systems, new survey results show the global pandemic could derail a decade-long effort to shift payment for healthcare services from a focus on volume to one on value. Value-based payment models, such as accountable care organizations (ACOs), incentivize physicians, hospitals, and all healthcare providers to work in a more coordinated manner, focusing on delivering high-quality care while avoiding unnecessary utilization and costs. An increasing number of providers have embraced the ACO model and its focus on accountability for cost and quality, but new survey results demonstrate that normal accountability is not appropriate in the face of a global pandemic.

In early April, the National Association of ACOs (NAACOS) emailed all Medicare Shared Savings Program (MSSP) and Next Generation ACO Model participants, including NAACOS members and nonmembers, with a request to complete an online survey focused on the effects of COVID-19 on ACOs. There were 304 responses from 226 ACOs across the country. The results of that survey send a clear and strong message that ACOs are very concerned about the effects of COVID-19 on their ACO. As shown in more detail below, those worries are illustrated by almost 60 percent of respondents in risk-based models reporting they are likely to quit the ACO program to avoid financial losses stemming from the pandemic, and 77 percent of ACOs reporting they are “very concerned” about the impact of COVID-19 on their ACO’s 2020 performance.

A vast majority of ACOs are very concerned about the effect of COVID-19 on their ACO

When asked how concerned ACOs are about the impact of COVID-19 on their ACO’s 2020 performance, 77 percent report being “very concerned” and 17 percent report being “somewhat concerned.” The remaining 6 percent of responses were split between being not concerned, neutral, or don’t know.

Further, 90 percent of ACOs report that the COVID-19 pandemic will have a significant or very significant effect on their ACO’s ability to earn shared savings.

While the concept of foregoing shared savings may seem like a small price to pay in an economy teetering on the brink of significant recession, shared savings payments for ACOs are often the only funding they have to keep the ACO functioning. Medicare does not pay ACOs a per-member, per-month or per-year payment, nor does it provide additional support to fund ACO operating costs that go towards additional clinical resources, data analytics, care coordinators, health IT, compliance, or administration.

A large portion of risk-based ACOs are likely to quit over concerns about COVID-19

In response to an emphasis in recent years for ACOs to assume increasing levels of financial risk, currently more than 40 percent of Medicare ACOs are in risk-based models. The MSSP has a May 31 deadline for risk-based ACOs to give notice of quitting to avoid losses, as well as potential savings opportunities, for this year. The survey found that 56 percent of risk-based MSSP ACOs report they are likely to leave the MSSP in response to concerns about having to potentially repay losses in 2020 because of COVID-19.

Uncertainty and difficulty predicting performance are notable concerns

A likely driver for ACOs to quit the program is the uncertainty about costs, quality, and utilization for 2020. COVID-19 has upended normal utilization and care patterns, disrupting ACOs’ ability to employ successful population-health strategies and causing tremendous uncertainty about costs. There is also notable uncertainty on how the pandemic will affect other aspects of the ACO program, such as changes to acuity or risk scores, diminished opportunities to meet quality requirements related to preventive care, and which patients the ACO will be accountable for this year. This uncertainty was strongly noted by survey respondents in comments, and 65 percent reported that the scope of the effects of COVID-19 will make it very difficult for them to accurately predict their ACO’s 2020 performance.

From the Conclusion

The survey results detailed above paint a potentially grim picture for ACOs and the move to value. Advancing value-based care has been a priority of Congress and the administration. If the Department of Health and Human Services’ goal remains moving all Medicare payments into alternative payment models by 2025, then it is imperative that the government appropriately adapt models to withstand the highly unusual circumstances brought on by COVID-19. Specifically, NAACOS and other leading healthcare organizations are calling on Congress and the administration to cancel all losses for ACOs for Performance Year 2020. More ACOs have assumed downside risk in recent years, which has been a priority for the administration. Simply put, ACOs’ acceptance of financial risk did not account for a global pandemic. ACO providers are risking their lives treating COVID-19 patients, they should not also be required to risk their businesses, many of which are not equipped to potentially pay millions to the government for increased costs from COVID-19.

https://www.naacos.com…

Comment:

By Don McCanne, M.D.

Accountable Care Organizations (ACOs) were established on the theory that by making providers accountable for the health care they were providing, you could improve quality while lowering costs. They were the policy community’s model of replacing volume with value. The enthusiasm amongst the bureaucrats has been so great that it has been the intent to move all Medicare payments into such alternative payment models (APMs) by 2025.

The experience to date has been very unimpressive. Significant cost savings have not been realized, and, in spite of the administrative excesses of quality determinations, they have failed to demonstrate significant improvements in quality that really counts. Further, it was never clear how they intended to reduce volume when most health care services are considered beneficial, even for those visits that merely provide reassurance. There is nothing like a pandemic to demonstrate that volume must always be a consideration in health care delivery and its financing system.

There is nothing good about the COVID-19 pandemic, but it is demonstrating what a ridiculous concept value-based purchasing is with its ACOs, APMs, MIPS (Merit-based incentive payment system), and specifics such as downside risk penalty systems. Though the policy community has been reluctant to back off of advocating for this screwy concept, we now see that the physicians and other providers out in the field living with this system are no longer able to tolerate it. Policy wonks are finally going to lose this one by fiat since their providers will walk away. In a month it could be that ACOs will have been dumped on the trash heap of terrible policy ideas (though that could be delayed if Congress were foolish enough to use bailout funds in an unsuccessful attempt to try to salvage the ACOs).

So are there any policy ideas out there that would work? Regular readers know that there certainly is one and that is a well-designed, single payer model of an improved Medicare for All. The design would include surge capacity. Although transitional queues for non-urgent problems might be necessitated during a pandemic, everyone would receive essential health care services without having to negotiate financial barriers, not to mention resolving inefficiencies and inequities in our financing system for all time. Wish those policy folks would finally get this into their heads. Maybe we could talk with them during their wake for the ACOs, hinting that single payer could be their policy reincarnation.

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Medicare for All Explained Podcast: Episode 32

Interview with Dr. David Himmelstein

April 12, 2020

PNHP co-founder Dr. David Himmelstein recalls the organization’s beginnings in the mid-1980s, a time when many health care advocates were on the defensive. He also discusses the ongoing COVID-19 pandemic and the need for not just universal coverage, but paid sick leave, national coordination and health planning, and major changes to the way hospitals are funded.

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

Transcript: Episode 32, If There’s an Argument for Medicare for All That Ought to Convince Everyone,It’s This Epidemic

This is computer generated transcript and may not be completely accurate. Some minor editing has been done for clarity.

Joe Sparks – Host
David Himmelstein, MD – Guest

JS: 0:05
Welcome to Medicare for All Explained. This podcast will enlighten our listeners and dispel the distortions that’s around Medicare for All. Medicare for All Explained is produced in collaboration with Physicians for a National Health Program and is hosted and produced by Joe Sparks. I’m your host Joe Sparks.

JS: 0:29
This is Episode 32, “If There’s an Argument for Medicare for All That Ought to Convince Everyone, It’s This Epidemic.” My guest, David Himmelstein, MD, is a Distinguished Professor of public health and health policy in the CUNY School of Public Health at Hunter College. Dr. Himmelstein is a co-founder of physicians for a national health program. He has authored or coauthored more than 100 journal articles and three books, and is the top expert on the waste and abuse of our current healthcare system. Dr. David Himmelstein, welcome to Medicare for All Explained.

DH: 1:18
Thanks for having me.

JS: 1:20
So, you are one of the co-founders of Physicians for a National Health Program. And I would like to ask how that started, and was there a national emergency or a medical crisis that cause you to start PNHP?

DH: 1:40
We started PNHP back in the 1980s during a period when Ronald Reagan was president and really the care for for people and people of color and many working Americans was under attack. Medicaid programs were being cut nationally and in many states. And we really thought we needed a vision of what the healthcare system ought to be not just trying to defend Medicaid and other really inadequate programs for the poor, which had been pretty much what the Democrat. Democratic Party’s strategy has been is they took a defensive stance. And a number of us said, you know, the health care system in the US is not something we can defend at this point. We need a vision of something much better than this. And said we needed to put forward a view of national health insurance, of national health program that would, would really not just keep where we were, but move us much forward. And so in the 1980s, a number of people started really developing ideas for single-payer national health program. And at that time, the Gray Panthers, which was a progressive seniors group was going to run a ballot initiative in Massachusetts, instructing messages to Congress people to support single-payer national health care reform. And they were concerned that the Massachusetts Medical Society, the physicians group would oppose this publicly and would cause problems in the referendum. And a number of us who were physicians involved in that effort, the ballot initiative for single-payer said we need to rally physician support to counter possible opposition from the Mass Medical Society and other groups. So we came to a conference for clinicians caring for the poor that was being held up in New Hampshire with a proposal that we needed to start a physicians group that was explicitly in favor of national health insurance or single-payer reform. And our colleagues greeted that enthusiastically and said let’s, let’s go ahead and do it. So we moved ahead with it at that time, that was, I think, the summer of 1985.

JS: 4:31
And why specifically, did you choose a single-payer system?

DH: 4:36
Well, we’ve looked around the world at what worked in other countries and what wasn’t working. And it seemed to us that the most functional systems were single-payer and really what used to be called national health insurance. And a second reason was the Canada’s program by 1985 had been in existence for nearly 20 years, and looked to be working quite well. And it was an easy system to imagine a transition to it in the United States. So there are many other systems that that work well and that might have been useful models. The British National Health Service at that point, which had not been really starved of funds the way it was subsequently by Margaret Thatcher and others, but or the Swedish system or Danish system. But it was much easier to imagine a move to a Canadian style system because Canada, before its single-payer system, it had an almost the identical system to what we had in the US and still have today. And in in many respects, Canadian medicine, the way medicine is practiced and the way hospitals are organized and so on, is closely similar to to the US. So, it was very easy to imagine adopting a Canadian style program and that provided a concrete example of what we thought would work in the US.

JS: 6:15
I’d like to shift gears a bit now and discuss the coronavirus and I’d like to know what are the major issues with the coronavirus now?

DH: 6:29
Well, I mean the coronavirus is an extraordinary disaster that has revealed we weaknesses in many aspects of US society and many aspects of US healthcare. I mean in on the health side.

DH: 6:50
It’s really spotlighted how inadequate our public health preparedness is. I mean, we’ve been cutting public health funding for almost a generation in the US. Since 2002, the proportion of our health spending that’s gone to public health has been falling. So we’re now about 2.4% of total health dollars going to public health, and just as an example, Canada spends 6% of its health dollars on public health. And what that’s meant on the ground is we have about 50,000 fewer state and local health department employees than we had back in 2008. So we’ve lost 20% of all of the public health personnel in our country, and those are the people who do the contact tracing and and the epidemic control on the ground. They’re the frontline health workers for controlling epidemic. And as I said, we’ve lost 20% of them. So the first thing is the COVID epidemic. really highlights are inadequate planning for public health and staffing and funding of public health and planning at the federal level. I mean, the first thing that President Trump did after his inauguration on public health is he implemented a hiring freeze at the Centers for Disease Control and Prevention. The CDC had 700 unfilled positions, and we’re still suffering from that today. The inadequate staffing and inadequate preparation that the CDC. On the, on the healthcare side, so those are really public health things. But on the healthcare side, we know that tens of millions of Americans are afraid to go see a doctor or go to the emergency room because they’re worried about the cost that they might be stuck with. And again, in the face of an epidemic, that’s a horrendous problem, because the only way to stop things early is to find them early. And when people are afraid to seek medical care that keeps us from from knowing what’s going on early on. A related thing is the lack of sick leave for tens of millions of American workers means people really have to go to work even if they’re feeling sick because they can’t afford not too. And that means that diseases get spread because people in normal times work with the flu or with other communicable diseases. And that’s problem even at the best of times, but it’s disastrous, with things like the coronavirus. A third thing is we have no national coordination healthcare systems, so the market determines where beds are, and how many beds there are, and how many ICUs there are, and how many doctors of different specialties there are. So, rather than having some rational plan distribution of facilities, and, and personnel, we really have a market distribution. So you see today, what it means to have an excess of have some kinds of specialists who in this emergency we really don’t need. We’ve got lots of orthopedic surgeons and gastroenterologists and cardiologists sitting around really not doing anything. And we have a shortage of primary care workforce in the hospital, hospitalist specialists who care for inpatients who are so vital in this time of need. And also the lack of Central coordination means that there’s there’s no not just authority, but no government agency that can say well, here’s where we have the resources and things like masks and, and other protective equipment that’s vital here, or respirators because no one keeps track of how many respirators there are in different hospitals and where they’re needed.

DH: 11:21
And under any reasonable national health insurance program, we have government monitoring, monitoring, and coordination of where the facilities are, where they’re needed, and where, where they can best be deployed. So all of those things have tremendously weakened our responses to the coronavirus. And I guess the last thing is over the last 30 years, we’ve said hospitals ought to be run by businesses, like businesses. And what that means at a hospital is you don’t want spare capacity because you want to make a profit. That’s the only way you stay in business as a hospital today. And if you have unused, unused facilities, extra stuff around, that detracts from your profit,but that’s exactly what we need in an emergency like this. And again, you know, if we were planning, healthcare as a human need, not as a commodity and not as a profit making business, we would say, not just what’s the most efficient way of running a hospital today, but what do we need from this hospital? In case of emergencies, let’s provide for that. So, we don’t pay to our military, just have the number of boats that you’d need for everyday operation. We say to them, how many you need in case of an emergency. And that’s what we ought to be doing with our healthcare system as well, and private businesses can’t do that. We really need government to coordinate and really take the load in that way.

JS: 13:12
In that regard, I’d like to ask a couple questions. Do we have enough hospital beds and ICU beds?

DH: 13:21
It’s hard to say we have a maldistribution of hospital beds and ICU beds. We may have enough nationally, but they’re really distributed according to where they’re most profitable. And what’s most profitable in the way of building particular facilities. So, we got, for instance, lots of beds for high high profit procedures like cardiac surgery and, and orthopedics surgery, but not enough there are many other kinds of problems out there. We’re trying to convert on the fly the beds that we don’t need into the beds that we do need, but that’s cumbersome operation. But it’s not just the beds, it’s for personnel as well. So again, we have a lot of personnel who were devoted to things that at the moment we don’t really need. We probably should have a little bit more of a reserve of hospital beds. They don’t need to be in hospitals the way we’re used to thinking of. So, for instance, in building new hospitals or renovating hospitals, they can be built in a way that spaces can be converted in emergencies. For other uses, but that’s not been done by and large in the US because it’s not what you do if you’re trying to financially succeed in the hospital. So You can build ambulatory care space that can be converted into a hospital bed, even if it’s not used in that way every day. And in Israel, for instance, one of the new hospitals that was built a few years ago, the garage was built in such a way that it can be quickly converted into a large additional hospital space with the equipment actually stored in in the walls and storage facility of the garage really ready to be converted on short notice into functioning hospital beds. So, in designing our system, we need to design that redundancy that may not be just sort of extra beds waiting to be filled, but thinking about how spaces and and personnel can be used for other than their everyday use.

JS: 15:57
And one of the issues also is of course ventilators and personal protection equipment. Is it that hospitals haven’t stored enough? Or is there, or is it that there are problems with the national stockpile or both?

DH: 16:12
Well, I think two things. One is that there is a problem with the national stockpile, which, by the way, the government agency that holds the national stockpile was moved from a competent health agency to a part of the government that has no experience with that sort of thing. That was another thing that Trumps did. And we have heard now reports that some of the ventilators when they have arrived are not in working condition, which may relate to the agency that was actually storing them not doing a proper job with it. But I think you mostly need a centralized stockpile of extra supplies like ventilators and protective equipment, and that our government has really fallen, fallen down on the job of that. The second thing is, the government didn’t move with any kind of speed to say, let’s get stuff being manufactured. So it’s just about a week ago, I guess, or even less than that, that Trump ordered GM to go ahead and produce ventilators Well, it was foreseeable eight weeks ago that that was going to be needed. And frankly, GM had started to do it a week before Trump ordered them, but if they’d had an eight week head start and the president had ordered it at that time, which public health experts were saying needed to be done,we’d already have those ventilators being delivered today. So it’s both failure to stockpile stuff adequately, and maintain them in the stockpile and a failure of government once the epidemic was headed our way to act quickly.

JS: 18:09
One of the big issues is having the right number of tests or getting people tested. Then of course, the World Health Organization has developed a test and we’re still working on getting a test. How do you think that has affected things, and do you think we should just be using the test kits from the World Health Organization?

DH: 18:35
Well, I think there’s no doubt that the lack of early testing was part of the reason we have a disaster today. The key to containing an epidemic is knowing who is infected, isolating them so that they don’t infect additional people and caring for them while they’re being isolated. And because we didn’t have tests, we couldn’t find out who who had the infection, and who was spreading it. And by the time we began to do large numbers of tests, we, we clearly had many, many, many people already infected and spreading the disease. So large scale testing early on was critically important, and we failed in it. And we clearly should have accepted the test from the World Health Organization. We now have tests that have been developed in the US that are are in the field that are being used, but we still don’t have them in large enough numbers. And that remains an enormous problem in our country. So other countries that did a much better job at containing the virus, like South Korea did, large numbers of early tests, and the didn’t take this jingoistic approach of we’re not going to accept the test because it’s not American.

JS: 20:03
So what do you think we need to do to mitigate the effects of the coronavirus at this point? Is there anything that you haven’t discussed?

DH: 20:14
Well, I think we need to do a couple of things. One is we actually need sick leave for every American worker. So the Congress passed a bill which they claimed was going to provide sick leave, but it exempted firms that had more than 500 employees, and that’s about half of all American workers who aren’t covered by that law. So we need we need a law that says every American is entitled to sick leave. That’s critically important. The second is Congress again passed a law saying that every American could have free coronavirus testing once the tests are available, But what we don’t have is we don’t have coverage for people to get care if they actually get sick. So we’re headed towards a financial disaster for many Americans, both because many who are uninsured, and then the number of uninsured is growing very rapidly work. We know that. Our best estimate is that about a million and a half Americans have lost coverage in just the last two weeks, and probably another six or 7 million more will be losing coverage in the next month or two. So we have a huge number of people who are uninsured, and if they do get sick from coronavirus, will face disastrous medical bills. And even for people with coverage, the co-payments and deductibles will will bankrupt many many tens of thousands of them. So we actually need urgently coverage for everybody for not just coronavirus, but for every kind of medical care. But at this emergency there’s no reason Congress can say we will extend Medicare to cover all corona coronavirus expenses at this point. But in the longer term we need universal coverage to to address not just this epidemic, but future epidemics. If there’s an argument for Medicare for All that ought to convinced everyone, it’s this epidemic.

JS: 22:35
Well, that was going to be somewhat my next question. How do you think Medicare for All would help in battling the coronavirus? And in general, is there anything else you’d like to add about how Medicare for All would help?

DH: 22:58
I think it would have allowed people to get medical care earlier in their illness and would have helped us in the isolation. But as I’ve said, we need a restructuring of our healthcare system, which will take some time even after Medicare for All is passed. But it would provide us the tools to restructure our healthcare system. So, one of the things that we’ve always said about Medicare for All is we need to change the way we fund hospitals. We don’t want to just pay them the same old way, and and really let them choose what services they want to offer based on what’s profitable. We want to say hospitals get global budgets, like fire departments or schools, and rather than billing patient by patient, and the decision about where new hospital investments are made shouldn’t be up to just the hospital. It actually needs to be based on planning for where facilities are needed, so we needed a different way of distributing the money that’s used to upgrade hospitals and other healthcare facilities and build new ones. And that Medicare for All would also allow us to do, but it would take probably five or even 10 years to really build out the healthcare infrastructure that we need to fight epidemics optimally. But in the meantime, we could quite quickly assemble the data systems that would allow us to collect data from hospitals about whom they’re treating, and what kind of facilities and stockpiles they’re holding. That would allow us to coordinate the response much better. So, we’re hearing from colleagues around the country at this point that the CDC was basically calling around to hospitals to try and get reports on coronavirus patients or coronavirus test results rather than having in place some data systems that would allow the timely collection of that data as a routine and ongoing thing. And that really reflects the fragmentation of our system and the lack of of any government coordination of our system.

JS: 25:31
So one of the things, just building on that point, and it’s something you mentioned earlier, is Medicare for All would make it much easier to have a national health care policy where we do a strategic allocation of resources.DH: 25:49 That’s exactly right, and that’s part of what we need is over the last four or five decades in this country, we’ve said we will give hospitals incentives and other facilities incentive to build what’s profitable and regardless of whether it’s needed or not, and the result is that we have a surplus of some kinds of care, and some kinds of facilities, and a real lack of other kinds of things. And we need to move in a very different direction than that and really base our system on, on making sure we have what’s needed. And that’s reflected in all kinds of ways. So, we have a tremendous shortage of primary care in the United States, and we know that health systems that have ample primary care have better outcomes. Patients lives are longer and better. But primary care doctors make much less than specialists, so we’ve we’ve got a surplus of many kinds of specialists, and a shortage of primary care, and a shortage of mental health care in our society. So we need to move towards a system that meets needs rather than seeks profits.

JS: 27:17
I have another question, what is your prognosis for how bad or what the effects will be of the coronavirus?

DH: 27:28
I think we’re facing a very, very rough period. I think we’re going to see many, many, many, many,many deaths. I guess the estimate that currently being issued is something like 120,000 deaths. That may be even conservative. So this is a national disaster on a scale we haven’t seen since the 1918 flu pandemic. And the question of what comes out of that for our society, I think we haven’t even begun to grapple with. We could take that as a cue to do some very good things and, and understand what led us to this disaster and lack of preparedness, lack of ability to effectively deal with this epidemic. And recognize that we’re all in this together that actually a dog eat dog world where we say if someone else is homeless, if someone else doesn’t have medical care, that’s not my problem. I think one of the lessons of this is that that’s everyone’s problem. That rich people are in trouble along with poor people in an epidemic. So one possible outcome is an understanding that we need to change our society in a big way, similar frankly, to some of the things that came out of the Great Depression where, you know, we got Social Security, and many other critically important social programs out of out of that terrible period. So I think the optimistic view is that we can learn important lessons and move ahead in important ways. And the pessimistic view is that we’ll go back to the old ways and and set ourselves up for yet another disaster.

JS: 29:24
Before we end, is there anything else that you would like to add?

DH: 29:30
Well, I think that the time is now to begin to plan not only for what we’re doing during this terrible pandemic, but really to contemplate what needs to be done next. So, I think both for Medicare for All, for the public health workforce, for security of people in their jobs and their homes, we need to think about how to rebuild our society after this epidemic is over. And progressives need to start with that task very soon if they are not starting there already.

JS: 30:09
Dr. Himmelstein, thank you so much for being on Medicare for All Explained.

DH: 30:16
Thanks for having me.

JS: 30:19
You have been listening to Medicare for All Explained. Information about this podcast can be found at our website, MedicareForAllExplained.org. The music for this show is “Super Bubbly” by Jesse Spillane. The logo was created by Lilly Sparks. Thank you for listening.

Transcribed by https://otter.ai.

Malcolm Gladwell: The lesson of the COVID-19 pandemic

THE WORLD AFTER COVID-19 - with Malcolm Gladwell

Munk Dialogue, April 9, 2020

Rudyard Griffiths: What do you think will be the best thing coming out of this?

Malcolm Gladwell: If I had to identify the best thing that could come out of this, it is a resurgence in the profile and importance of the public health community. If you look back on the 20th Century, what is the great success story of the 20th Century? It is public health. It dwarfs every other thing we invented in the 20th Century. The 20th Century is the century where a group of public health professionals stepped forward, took control of the way we live our lives, and managed to eradicate a whole raft of extraordinary diseases, fundamentally changed the health care profile of billions of people around the world, permanently made lives better for untold people in every corner of the planet. To me that’s the story. Those successes were so rich and so dramatic, that I think we began to take them for granted, and we pushed the public health world aside, and we went on to other things. Right? We fell in love with fancy technology, and we fell in love with the Internet, and we fell in love with all kinds of other… and we silenced and marginalized all of those (public health) voices, to our enduring discredit. And what I hope happens out of this is that we invite public health folks back to the center of the conversation. And we say, you know what? You know who should be leading the conversation about the health of our population? The public health people. They’re the ones. They have the most important lessons to teach us. They’re the ones whose priorities are in order. They’re the ones who are looking for resurgent viruses coming out of some distant corner of China. I hope we’re going to invite them back to center stage, and I hope they remain there for a good long time.

https://munkdebates.com…

Comment:

By Don McCanne, M.D.

May we act on the lesson of the COVID-19 pandemic.

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Beware the ACO enablers

ACO consultants getting more attractive as downside risk approaches

By Maria Castellucci
Modern Healthcare, March 21, 2020

While Caravan Health, one of the consulting firms typically called ACO enablers, is taking on all the downside risk for some of its customers, other companies have long baked into their business model that they will take on some of it, sometimes half or more, depending on the ACO.

As a result, some leaders of these firms said they are seeing an uptick in independent physicians already participating in the Medicare program interested in joining them as they are forced to shoulder downside risk soon or drop out.

Downside risk required

The CMS recently finalized changes to the Medicare Shared Savings Program that require participants to enter a downside-risk track within three years. The original timeline was six years.

“We are seeing strong interest,” said Asit Gosar, CEO of Evolent Care Partners, which has an ACO client with independent primary-care practices assigned 60,000 Medicare beneficiaries. “We are talking to over 30 organizations 
 They see an advantage in working with someone who gives them the capital as opposed to doing that all by themselves with thin balance sheets.”

Similar to other ACO enablers, Evolent takes a share of the bonuses as well as a percentage of the losses should they occur. In exchange, Evolent helps independent practices get set up in the program by paying for needed infrastructure support such as data capabilities and hiring nurse practitioners or other staff who can help with population health initiatives like wellness visits.

Aledade, an enabler with 38 ACOs in the Medicare program, partners exclusively with independent physician practices.

Aledade has historically taken on the “lion’s share” of the risk for its ACOs in addition to cashing in on a percentage of bonus payments, said Dan Bowles, senior vice president of growth and network operations at the company. The arrangement is how Aledade makes 90% of its revenue.

Small practices don’t have the capital reserves to take on downside risk entirely on their own, said Dennis Butts, partner at Guidehouse (formerly Navigant), a consultancy that has researched the Medicare ACO program.

“If they lose a million or two, that can cripple a smaller practice,” he said. “It has become more important for organizations to reduce the risk and you can (do that) by having some form of insurance. That can be through having an enabler to take on that risk for you or joining a larger network.”

A system approach

Although physicians have the peace of mind that they aren’t on the hook for all the losses, they still feel pressure from their peers and the enabler to perform well in the ACO.

ACO enablers also have mechanisms in place to boot out bad actors. Physicians who are part of Aledade ACOs can reassess a practice’s involvement in the organization if they “aren’t committed to the initiatives necessary for success,” Bowles said. But he noted that doctors being removed from an ACO is “relatively uncommon.”

Caravan founder Lynn Barr said Caravan monitors practices on a quarterly basis and if they don’t hit benchmarks they can be kicked out if performance doesn’t improve. “If they haven’t hit their mark by June, we put them in remediation. And if they haven’t by September, they are out of the ACO,” she said.

In response to a request for comment about the practice of ACO enablers taking on most or even all the downside risk for providers, a CMS spokeswoman said, “Where appropriate, we support giving ACOs the flexibility they need to be successful.”

Similar to its competitors, Privia Health shares in the savings and downside with its customers. It’s important the doctors have “skin in the game” to encourage improvement, chief clinical officer Keith Fernandez said. “Them being worried about the outcome counts,” he added.

Researchers evaluating the ACO program said the relationship between ACO enablers and doctors is generally one that works. Because enablers are so reliant on their ACOs to do well in the program to stay financially viable, they are the ones keeping the doctors accountable.

Physicians “are working with somebody (ACO enablers) whose entire business model is predicated on them being successful,” said David Muhlestein, chief research officer at Leavitt Partners. “Not only do they not want to pay back losses, they are dependent on the ACOs being successful in order to stay in business.”

Power in scale

Another benefit of joining enablers is scale. Although Medicare requires an ACO to have at least 5,000 attributed beneficiaries, the more lives the better to remove uncertainties that could lead to losses, said John Feore, associate principal at Avalere Health, a research firm.

“The smaller you are, the fewer beneficiaries you have in your network that are assigned to you and what that can lead to is greater volatility in spending over the course of the year,” he said. “A response to that is ACO enablers, or other organizations, that are able to bring multiple ACOs together under one umbrella and what that can do is mitigate, and almost eliminate, the variation in spending that is going to occur naturally with a senior population.”

Caravan Health spent much of last year consolidating ACOs to increase the number of beneficiaries assigned to each one. Caravan made the changes after the CMS finalized its changes requiring the accelerated transition to downside risk. Caravan went from 38 ACOs to 12.

“We are creating a security for them by putting them in these large enclaves where the numbers aren’t all over the place and taking them to risk,” Barr said.

Caravan was able to convince providers to consolidate into larger ACOs by agreeing to take on 75% of all losses should they occur in downside-risk tracks.

The future of the program will likely see larger ACOs given the required path to downside, according to researchers.

Barr said she predicts the future of the program is large ACOs. “This is a program that unless we innovate and pull our lives together, we are all going to fail. I can see it in the data,” she said.

Gosar at Evolent also said scale is part of its business strategy going forward.

“In the risk-taking portion of healthcare, which has historically been health insurance companies, the smallest plans are (covering) hundreds of thousands of lives. Sixty thousand (beneficiaries) is just the beginning” he said. “We want to be able to grow to a much larger risk-sharing business.”

https://www.modernhealthcare.com…

Comment:

By Don McCanne, M.D.

Accountable Care Organizations (ACOs) were established under the theory that by making the providers accountable for the health care provided, value could be improved. The providers would then share the profits with Medicare (sharing upside risk), but if there were losses, the providers would have to refund to Medicare some of the payments they received (sharing downside risk). It turns out that sharing downside risk is a better deal for Medicare, and thus CMS is pushing the ACOs into downside risk arrangements.

Much has been written about the questionable rationale of ACOs. They add more administrative complexity which wastes funds that should be going to patient care. It is not clear why physicians would want to enter an agreement with Medicare to share some of their profits with Medicare or to pay Medicare what are essentially penalties when they have losses. Looks like a win-win for Medicare and a loss-loss for the providers. Regardless, the business model of ACOs could not help but attract the attention of business managers and their capital.

So we have a new industry of ACO enablers. They provide yet more administrative services, wasting even more health care dollars – a unique characteristic of the U.S. health care financing system. Most of their revenues come from sharing the upside risk – profits – of the ACOs.

What are they providing that would make them attractive to the providers? Capital – to insure against downside risk losses – probably the most important reason that physicians are wary of ACOs. So how do the ACO enablers enable the ACOs to profit to ensure their own financial success? Their methods smack of managed care. They bring in “nurse practitioners or other staff who can help with population health initiatives like wellness visits.” They monitor practices and boot out physicians who don’t meet their benchmarks. Also they merge ACOs that are under their umbrella in order to dilute the financial impact of the higher risk patents. It’s about scale. As one CEO said, “We want to be able to grow to a much larger risk-sharing business.”

Capitalism. These guys bring in a few bucks, use them to displace functions of the private insurers and take over the health care delivery system, and then scoop up the profits, all in the name of enabling the ACOs. Sorry, America, we’re being screwed again.

Wouldn’t it be better to spread risk by establishing one single, universal risk pool that includes everyone? And, capital? Wouldn’t it be better to use our own funds paid through equitable taxes in amounts that each of us could afford? And the monetary return on that capital? Remove the profit line from the balance sheets since this isn’t about capitalism; it’s about social insurance, and our return is better health for all of us. And MBA managers? Boot them and their corporate model out.

You know, this sounds like we could take our Medicare program, fix it so it works better, and then expand it to cover all of us; maybe call it the single payer model of Medicare for All. Does anyone else think that’s a good idea? The ACO enablers probably won’t like it.

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Nearly 5 Million Lost Health Coverage in Past Three Weeks; 13.5 Million Likely to Become Uninsured by June 30

New Estimates Include Dependents of Laid off Workers

FOR IMMEDIATE RELEASE: April 9, 2020

Contact: Clare Fauke, Physicians for a National Health Program, 312-782-6006, clare@pnhp.org

4,805,894 American workers and their dependents have lost health insurance coverage in the past three weeks, according to a new estimate by researchers at The City of New York’s Hunter College and Harvard Medical School. The researchers also estimate that a total of 13.475 million will join the ranks of the uninsured by June 30, raising the number of uninsured Americans to about 43 million.

The new figures include coverage losses among newly-unemployed workers as well as their dependents covered under job-based family policies. The figures update previous estimates that the same researchers published online in the Annals of Internal Medicine on April 7, 2020. Those previous estimates only included workers themselves who were laid off during the last two weeks of March, and did not include dependents losing family coverage because of layoffs, or the most recent week of data.

The new estimates analyzed U.S. Labor Department data on the number of new unemployment claims in each state, and differences in the likelihood of being uninsured among workers with jobs (and their dependents) and those who have lost jobs (and their dependents).

Based on an analysis of Census Bureau surveys of health insurance coverage, the researchers estimated that 15.6% of laid-off workers become newly uninsured, and that for every 100 workers who lose coverage, about 83.7 dependents also lose insurance. They applied those estimates to the Labor Department’s figures (released on April 9) indicating that 16.780 million people filed new unemployment claims in the past three weeks.

The June 30 coverage loss estimate was based on a Federal Reserve economist’s projection that 47.05 million workers will lose jobs by the end of June. The researchers noted that their figures do not include coverage losses among self-employed persons, or other job losers who did not file unemployment claims or their dependents.

The research was carried out by Drs. Steffie Woolhandler and David U. Himmelstein. Both authors are internal medicine specialists who serve as distinguished professors at Hunter College and lecturers at Harvard Medical School.

Dr. Woolhandler commented, “Our health financing system is in tatters, as our nation faces the biggest health crisis in a century. Millions are losing coverage each week and hospitals are struggling to make payroll. States can’t fill the gaps because tax revenues are plummeting and they, unlike the federal government, are required to balance their budgets each year. In this emergency, Washington must step in to protect beleaguered families by expanding Medicare to cover all of the uninsured.”

In addition to their academic positions, Drs. Woolhandler and Himmelstein founded Physicians for a National Health Program, a 23,000 member organization that advocates for single-payer Medicare for All.

Private insurance has failed us

By Patty Harvey
Times Standard (Eureka, Calif.), April 9, 2020

“April is the cruelest month.” T. S. Eliot’s saturnine declaration foreshadows what is developing into the greatest challenge to this country and to the world in modern history.

The very first days of April, indeed, bring us shattering statistics and projected horrors to come. We look to our national leaders for guidance — and what has a ‘Trump April’ produced so far? A frightening lack of support for a unified public health approach to address the crisis, repeated obfuscation and denial of events, and, even worse, a failure to accept responsibility to address the health needs of Americans: Jared Kushner exposed this jaw-dropping philosophy with his recent declaration that the federal stockpiles of personal protective equipment and ventilators were not meant for use by the states who must compete against each other and the government for live-saving supplies.

And what about the ever-growing 10 million job losses across the nation, so many of which mean loss of health insurance along with income — two clearly incompatible events? Will one-time bailouts cover weeks, possibly months of ongoing family costs? What of any personal medical emergency, even non-COVID-19 related? In response, we are told there will be no further open enrollment in Obamacare this year. No rationale is offered for this appalling denial to those most in need of health care—the only explanation left is political motivation from the point of view of animus to all things “Obama,” and the administration’s anticipated wholesale overturning of that program by a conservative Supreme Court.

The disaster ensuing from the pandemic paints a stark reality of the danger and inutility of tying health insurance to employment. Remember the outrage of a Buttigieg, a Klobuchar, a Biden railing against the idea of Medicare for All “kicking millions off their employer-linked health plans.” Remember, also, that with Improved Medicare for All, every resident would be guaranteed health care from any doctor, hospital or clinic, from birth to grave without regard to employment, wealth, race, gender, marital or any other social status, with no premiums, co-pays, or deductibles. Many studies have confirmed that not only can we afford to do this but we must do it to avoid economic disaster due to the $4 trillion per year-and-rising cost of our current non-system. Such is the proposed single-payer Medicare for All replacement for those employer-based health plans. By contrast, how are those beloved plans working out now? What is the safety net for those being “kicked off” right now?

Vague murmurings from the Trump administration suggest that perhaps Medicare and Medicaid could be commandeered to meet that need (one wonders, do they see how that sounds like Medicare for All) — with no actual plan proposed. The government also has avoided mentioning options remaining for the uninsured. Needless to say, they are poor: there is COBRA (more expensive than any current plan), there is “’proving’ you lost your job due to Coronavirus” (paperwork that could take weeks/months if doable at all), or one may apply for Medicaid (if your state has expanded its use and if you can negotiate the bureaucratic hoops with built-in barriers). In Florida, for example, some 400,000 low-income uninsured adults don’t earn enough for subsidies to buy private insurance but who make too much to qualify for Medicaid.

If nothing else, this pandemic has painted a clear and compelling picture of how desperately we need Improved Medicare for All, a single-payer healthcare system that puts public health above private profit and eliminates, especially today, the loopholes and cracks through which our citizens are increasingly falling. Perhaps then we will celebrate April as a harbinger of re-birth and the kindness of coming springtime.

https://www.times-standard.com…

UnitedHealth, Cigna sued for underpaying out-of-network providers

By Shelby Livingston
Modern Healthcare, April 6, 2020

Several behavioral health providers and patients sued UnitedHealth Group and Cigna subsidiaries for allegedly underpaying the providers for out-of-network claims, leaving patients with massive medical bills.

The lawsuits, filed last week in the U.S. District Court for the Northern District of California, claim that United Behavioral Health and Cigna Behavioral Health violated federal and state laws by systematically reimbursing the out-of-network providers for mental health and substance abuse treatment at unreasonably low rates in violation of the terms of their patients’ insurance plans.

Patients were left with big balance bills that often amounted to 90% of the cost of their care, the complaints allege.

The providers, which provide intensive outpatient program services, claim that they confirmed with UnitedHealth and Cigna that their patients had active coverage for out-of-network behavioral health services before providing treatment, and that the insurers assured the providers they would be paid at “usual, customary and reasonable” rates.

Instead, the insurers enlisted and paid financial incentives to Viant, a vendor that is also named as a defendant in the four cases, to reprice each out-of-network claim in a way that was not based on that reasonable rate and not varied based on geography, according to the complaints. Viant is owned by MultiPlan, which describes itself as healthcare cost-management company.

The patients, meanwhile, were enrolled in UnitedHealth or Cigna employer health plans offering out-of-network coverage for mental health and substance use disorder treatment. They argue that because the insurers underpaid their providers, they were left on the hook for bills averaging $30,000 each.

https://www.modernhealthcare.com…

Comment:

By Don McCanne, M.D.

With the COVID-19 pandemic, our health care system, our economy, and our personal lives are in turmoil. One of the lessons is that it is now more clear than ever that we are not receiving adequate value for the $4 trillion that we are spending on health care. Clearly we need comprehensive reform of our health care financing system, but it is crucial that in the confusion we not lose sight of the problems that need to be rectified. Those problems that are resulting in fragmentation and dysfunction in financing care are typified by the business model of the private insurers (as opposed to the patient service model that would typify a public insurer).

Today’s message reminds us of what is wrong with placing control of our health care dollars in the hands of private insurers. Two of the nation’s largest private, for-profit insurers have promised patients behavioral health services yet pay as little as 10 percent of the costs, leaving patients with bills averaging $30,000 each. To add insult, they step away from the transaction and hire a “cost-management” vendor to “reprice” the out-of-network claims, reneging on their assurance that they would pay “usual, customary and reasonable” rates.

Of the various reform proposals under consideration, sadly most would leave this inimical industry in control. The leading proposal – single payer Medicare for All – would remove the insurers and replace them with our own universal, equitable, public financing program which would ensure affordable comprehensive health care for all of us forevermore, amen. (It seems a generic “amen” is appropriate in these difficult times.)

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COVID-19 pandemic and the loss of health insurance

Intersecting U.S. Epidemics: COVID-19 and Lack of Health Insurance

By Steffie Woolhandler, MD, MPH; David U. Himmelstein, MD
Annals of Internal Medicine, April 7, 2020

During the final week of March 2020, the U.S. Department of Labor reported that a record number of workers—6.648 million—filed new claims for unemployment benefits. That beat the previous record of 3.307 million filings, which was set the week before, bringing the 2-week total to 9.955 million. This is just the beginning of the surge in joblessness due to the coronavirus disease 2019 (COVID-19) pandemic. A Federal Reserve Bank economist estimated that the ranks of unemployed persons will swell by 47.05 million by the end of June.

For many, job loss will carry the added sting of losing health insurance. Congress has moved to cover severe acute respiratory syndrome coronavirus 2 testing for uninsured persons, but did not include provisions to cover treatment of COVID-19 (or other illnesses). The recent $2 trillion bailout bill offered no new health insurance subsidies or coverage.

Estimating Coverage Losses

We estimated the likely effects of current job losses on the number of uninsured persons by using data from the U.S. Census Bureau’s March 2019 Current Population Survey on health insurance coverage rates among persons who lost or left a job. The uninsurance rate among unemployed persons who had lost or left a job was 26.3% versus 10.7% among those with jobs. Applying the 15.6–percentage point difference to the 9.955 million who filed new unemployment claims last week, we estimate that 1.553 million newly unemployed persons will lose health coverage. This figure excludes family members who will become uninsured because a breadwinner lost coverage and self-employed persons who may lose coverage because their businesses were shuttered, but are ineligible for unemployment benefits. If, as the Federal Reserve economist projects, an additional 47.05 million people become unemployed, 7.3 million workers (along with several million family members) are likely to join the ranks of the U.S. uninsured population.

Coverage losses are likely to be steepest in states that have turned down the Patient Protection and Affordable Care Act’s Medicaid expansion. In expansion states, the share of persons who have lost or left a job who lacked coverage was 22.1% versus 8.3% for employed persons—a difference of 13.8 percentage points. In nonexpansion states, the uninsurance rate among such unemployed persons was 38.4% versus 15.8% for employed persons—a difference of 22.6 percentage points. In other words, nearly 1 in 4 newly unemployed workers in nonexpansion states are likely to lose coverage, bringing their overall uninsurance rate to nearly 40%.

Our projections are based on differences in coverage rates for employed and unemployed persons in 2019, but there is little reason to believe that the predicament of unemployed workers has improved since then. Although many who lose their jobs are likely to be eligible for Medicaid or subsidized Affordable Care Act coverage, and some will purchase continuing coverage under COBRA (Consolidated Omnibus Budget Reconciliation Act), the same was true in 2019. Indeed, the situation may be worse today because some laid-off workers probably gained coverage through an employed spouse in 2019, an option less likely to be available in the face of the impending massive layoffs.

Urgent Policy Needs and Longer-Term Solutions

With jobs and health insurance coverage disappearing as the COVID-19 pandemic rages, states that have declined to expand Medicaid should urgently reconsider. Yet, the high uninsurance rate among unemployed persons in Medicaid expansion states underlines the need for action in Washington. Tax revenues are plunging, and all states except Vermont are required to balance their budgets annually. Hence, only the federal government has the wherewithal to address the impending crisis.

Thus far, neither Congress nor the administration has offered plans to expand coverage. Some have suggested that the federal government cover COVID-19–related care for uninsured persons through Medicaid, but some states would probably decline such a Medicaid expansion, leaving many newly jobless persons—and the 28 million who were uninsured before the pandemic—without coverage. Instead, we advocate for passage of an emergency measure authorizing Medicare coverage for all persons eligible for unemployment benefits.

Although the COVID-19 crisis demands urgent action, it also exposes the imprudence of tying health insurance to employment, and the need for more thoroughgoing reform. A trickle of families facing the dual disaster of job loss and health insurance loss can remain under Washington’s radar. However, the current tsunami of job and coverage losses along with a heightened risk for severe illness demands action. A decade ago, Victor Fuchs forecasted that “National health insurance will probably come to the United States after a major change in the political climate—the kind of change that often accompanies a war, a depression, or large-scale civil unrest.” Such a major change may be upon us.

https://annals.org…

National Health Insurance Revisited

By Victor R. Fuchs
Health Affairs, Winter 1991

National health insurance will probably come to the United States in the wake of a major change in the political climate, the kind of change that often accompanies a war, a depression, or large-scale civil unrest.

https://www.healthaffairs.org…

Who Shall Live?: Health, Economics, and Social Choice

By Victor R. Fuchs

National health insurance will probably come to the United States in the wake of a major change in the political climate, the kind of change that often accompanies a war, a depression, or large-scale civil unrest.

World Scientific Publishing Co., 1998
ISBN 9810232012

What’s Ahead for Health Insurance in the United States?

By Victor R. Fuchs, Ph.D.
The New England Journal of Medicine, June 6, 2002

National health insurance will probably come to the United States after a major change in the political climate — the kind of change that often accompanies a war, a depression, or large-scale civil unrest.

https://www.nejm.org…

Comment:

By Don McCanne, M.D.

About fifteen years ago, Victor Fuchs and I appeared on a debate panel on health care reform at Stanford School of Medicare. He spoke on his proposal for using vouchers to enroll in qualified plans that cover basic needs while individuals would have the option of paying more for additional services. Most single payer advocates would recognize that there would be serious deficiencies in such a system. I presented the case for a single payer national health program (with no deficiencies). (A third model, presented by the president of the California Medical Association, was not unlike what we now have, and thus can be ignored.)

In a way, I had an unfair advantage because, at my close, I quoted the wise words of Victor Fuchs himself: “National health insurance will probably come to the United States after a major change in the political climate — the kind of change that often accompanies a war, a depression, or large-scale civil unrest.”

Although I predicted that it would be years rather than decades into the future, it may be that such a major change is now upon us.

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