Resource – Page 1141

Miami hospice pioneers cash in

The Miami Herald
Dec. 28, 2003
Miami hospice pioneers cash in
By John Dorschner

Starting with a few volunteers and a small office in a Miami Methodist church, the minister and the nurse had a simple, idealistic mission. “We wanted to change the way America took care of terminally ill patients,” said Esther Colliflower, the nurse.

A quarter-century later, they head the largest hospice organization in the country, a for-profit firm specializing in the business of death. They have become fabulously wealthy, and now they are cashing in, selling out to Roto-Rooter in a $410 million deal announced last week.

The minister, Hugh Westbrook, stands to gain about $200 million and Colliflower somewhat less.

For some who work with the dying, these huge sums are unseemly. “We feel strongly that excellence in hospice care is a local, community-based concern
with neighbors, friends and families caring for one another,” said Mike Bell of the nonprofit Hospice of the Florida Suncoast, which serves the Tampa area. “Certainly when it’s a business, there’s a risk decisions might not be guided in a way that puts patient and family care first.”

Westbrook will remain a consultant, receiving $25 million over the next seven years, but control of the firm will pass to Tim O’Toole, a Roto-Rooter executive.

Graying baby boomers and the growing acceptance of hospices appear to make
this a solid growth business. Since the deal was announced Dec. 19, Roto-Rooter stock has shot up more than 35 percent.

“Under new ownership,” (investment analyst Jim) Barrett wrote, “we would expect (Roto-Rooter’s) VITAS’ overhead to be reduced.” Barrett didn’t specify, but a prime target for cuts would be the $5.8 million in annual charity care.

Is Westbrook afraid a bottom-line focus will reduce care for the dying? “We’ve always had fears,” he acknowledged, but said the firm is in good hands.

http://www.miami.com/mld/miamiherald/business/7582675.htm Comment: PNHP has not only supported an equitable system of funding universal health care, but we have also opposed the for-profit, corporate model in health care which must place the interests of investors above all else, including patients. The Roto-Rooter takeover of this hospice chain exemplifies why we need reform in both of these arenas of concern.

A minister and a nurse dedicated to meeting the needs of the terminally ill represent amongst the noblest of efforts of the healing professions. The hospice movement has been one of the more important advances in the care of those with the greatest needs for relief from suffering. If the story ended here, Westbrook and Colliflower might be considered for secular sainthood. But what happened? The for-profit conversion shifted the prime mission of the organization to its obligatory requirement to enhance shareholder value. Merger and acquisition activities are a major contributor to shareholder value. The surviving entity is mandated to further enhance value. And in hospice care, what could improve the bottom line more than eliminating uncompensated (charity) care?

The for-profit, corporate model must always place shareholders above patients, or risk SEC sanctions. But a public service model will always place the patient first. There has been no exception to this rule, and Roto-Rooter’s anticipated intent to ream out this hospice chain would be only the latest example.

Thus PNHP will continue to oppose for-profit, investor-owned corporate entities in health care. But our other mission of supporting an equitable, efficient method of funding care also applies here. A publicly-owned third party payer is ethically obligated to demand value from the provider of services. Diverting huge sums away from health care and to private investors does not provide health care value. If we had our own universal system of social insurance, we would be in a position to demand value from all providers of health care. Merely introducing an equitable single-payer system would have a suppressive effect on investor-owned entities since they would not be able to provide the same value as non-profit entities.

Let’s establish our own public health insurance program and thereby take control of our health care system. Let’s send Roto-Rooter back to the sewers where they can continue to do what they do well.

Star Tribune Editorial

Star Tribune Editorial: Hope, profit/Proper oversight in health care

Reading the Star Tribune’s excellent series of articles on Parker Hughes Cancer Center can’t have been easy for a number of people, chief among them patients of the clinic and their families. For many other readers, the distress comes from a question the series raised: If these descriptions of medical practice run amok were accurate, where was the oversight, from both government agencies and private health-care insurers?

The answer is partly hopeful, mostly unsettling. Parker Hughes is a private enterprise operating in a highly competitive, even cutthroat, field controlled by a few players with lots of money for image advertising and for hiring batteries of lawyers. Moreover, regulatory control almost always occurs after the fact. A lawyer who knows that and who is determined to take advantage of it can get away with a great deal for a very long time. Unless employees or patients of a clinic complain persistently, nothing is likely to happen. Even if many do complain, getting to the truth can be a long, expensive and litigious undertaking. Every “i” must be dotted, every “t” crossed, every legal challenge anticipated. That’s an undertaking which until almost the very end operates out of public view, as is now happening.

Partly the confidentiality is explained by medical care being the issue. Society generally grants professionally licensed health-care professionals wide latitude in exercising their best judgment. If a physician operates on the wrong person or the wrong leg, that’s medical malpractice for which clear remedies are available. But questions about the appropriateness of care are far more difficult to resolve.

Because the community of Minnesota physicians operating in some specialties is small, questions about appropriate care are referred to experts from other states — to avoid bias and to blunt inevitable counteraccusations of vendettas motivated by professional jealousy or competition. That’s expensive and time-consuming. It’s also, by law, confidential. All the public generally learns is the outcome.

Concerns about medical business practices, such as billing improprieties and excessive charges, should be, and indeed sometimes are, raised when those who pay much of the bill — state health officials for Medicaid and private insurers such as Medica, HealthPartners and Blue Cross — review the charges submitted by clinics and physicians. More vigilant review of charges needs to become a matter of course.

When the Legislature convenes early next year, it should examine several issues raised by the Star Tribune series. Most seriously, it should assess whether more sunshine is needed when licensed Minnesota health professionals are accused of wrongdoing. If, for example, an expert evaluation validates a complaint, shouldn’t the public at the least have access to the evaluation — if only to assess any disciplinary action taken as a result? Right now, discipline is too much controlled by the professions themselves, and within the professions there exists a high tolerance for some misconduct, such as inflating credentials or seeking favors from vendors.

More broadly, the Star Tribune has illuminated one more reason why the United States should consider some form of a single-payer health care system. Americans generally get excellent health care. But the patchwork system by which they get it drains a hugely excessive amount of revenue from the economy — even as many millions of people go without any coverage at all.

At every level, escalating health-care costs compete with funding for teachers and schools, police agencies and road repair. In many households, those costs compete with the rent and the telephone. For a variety of complex reasons, normal market economics don’t work in health care. It’s one area in which government generally can do a more efficient job of controlling costs and ensuring good care for all.

Health care eats up parish pay raises

shreveporttimes.com
December 26, 2003
Health care eats up parish pay raises
By Don Walker

Caddo Parish employees will receive an across-the-board 2.2 percent pay raise at the start of the new year that, for many, will be swallowed by a 32.7 percent increase in the amount they pay in monthly premiums for health care insurance.

Caddo Administrator Bill Hanna said the increase is unfortunate, yet unavoidable.

“All of this started back with 9/11. Home insurance, auto insurance went up, too. I don’t think there’s a person in the country who hasn’t been affected, and what caused this to escalate was a terrorist attack.”

http://www.shreveporttimes.com/html/E16C8335-645D-4C76-A4CC-22302D6CBB95.shtml

Comment: The rhetoric of the Bush administration certainly has been very effective, but apparently we need to work on ours.

_______________________________________________

Do the WSJ editors really understand HSAs?

The Wall Street Journal
December 23, 2003
Teddy’s Nightmare

The new year will bring something of a revolution in American health care. Insurance companies such as Golden Rule, Fortis and Aetna will soon be marketing Health Savings Accounts (HSAs), which promise a new era of individual choice for health insurance.

HSAs, the saving grace of the Medicare prescription drug bill, are the new and improved version of Medical Savings Accounts. They promise individuals and employers relief from spiraling health costs, and without the need for restrictive HMOs.

The basic idea is to pair an inexpensive insurance policy that has a high deductible — $1,000 or more for an individual, $2,000 for a family — with a tax-free savings account.

After the Mandela government deregulated South Africa’s private insurance market in 1994, HSA-type plans quickly captured about two-thirds of it.

That’s precisely the kind of success that Senator Kennedy and friends fear could happen here. Democrats know that a reinvigorated private health insurance market will end their dream of a Canadian-style health system.

“Once millions of HSAs are established, it will be almost impossible to reverse this program,” says the Web site for Physicians for a National Health Program, which also urges visitors to “CONTACT YOUR REPRESENTATIVES AND SENATORS IMMEDIATELY AND DEMAND THE URGENT REPEAL OF TITLE XII OF THE MEDICARE ACT!” Good to see they’re calm about the whole thing.

Critics have been making a number of dire predictions about the effects of
HSAs, none of which stand up to scrutiny. The most common is that HSAs would
attract a disproportionate number of “healthy and wealthy” individuals, “fragment the risk pool,” and drive up the cost of insurance for those who need it most.

http://online.wsj.com/article_email/0,,SB107214365174988600-H9jeoNmlah2op2vZ32Ib6iBm4,00.html

And…

eHealthInsurance.com
Frequently Asked Questions

What is an Indemnity Plan?

An indemnity plan is commonly known as a fee for service or traditional plan. If you select an Indemnity plan you have the freedom to visit any medical provider. You do not need referrals or authorizations; however, some plans may require you to precertify for certain procedures.Most indemnity plans require you to pay a deductible. After you have paid your deductible, indemnity policies typically pay a percentage of “usual and customary” charges for covered services; often the insurance company pays 80% and you pay 20%. Most plans have an annual out of pocket maximum and once you’ve reached this they will pay 100% of all “usual and customary” charges for covered services.

Many health insurance companies have moved away from indemnity plans and are instead offering managed care plans such as HMOs and PPOs. You may have few or no indemnity plan choices in your area.

http://www.ehealthinsurance.com/ehealthinsurance/FrequentlyAskedQuestions_1.html

And…

Internal Revenue Service
Notice 2004-2

This notice provides guidance on Health Savings Accounts.

Q-3. What is a “high-deductible health plan” (HDHP)?

A-3. Generally, an HDHP is a health plan that satisfies certain requirements
with respect to deductibles and out-of-pocket expenses. Specifically, for
self-only coverage, an HDHP has an annual deductible of at least $1,000 and
annual out-of-pocket expenses required to be paid (deductibles, co-payments
and other amounts, but not premiums) not exceeding $5,000. For family coverage, an HDHP has an annual deductible of at least $2,000 and annual
out-of-pocket expenses required to be paid not exceeding $10,000.

Q-4. What are the special rules for determining whether a health plan that
is a network plan meets the requirements of an HDHP (high-deductible health
plan)?

A-4. A network plan is a plan that generally provides more favorable benefits for services provided by its network of providers than for services provided outside of the network. In the case of a plan using a network of providers, the plan does not fail to be an HDHP (if it would otherwise meet the requirements of an HDHP) solely because the out-of-pocket expense limits for services provided outside of the network exceeds the maximum annual out-of-pocket expense limits allowed for an HDHP. In addition, the plan’s annual deductible for out-of-network services is not taken into account in determining the annual contribution limit. Rather, the annual contribution limit is determined by reference to the deductible for services within the network.

http://www.irs.gov/pub/irs-drop/n-04-2.pdf

Comment: The health policy literature is replete with studies describing the “death spiral” of skyrocketing premiums that result from drawing healthier beneficiaries out of risk pools, leaving higher-cost patients behind. The WSJ editors have exceeded their editorial prerogative when they state that the “dire prediction” of fragmenting the risk pool “fails to stand up to scrutiny.” The editors are entitled to their opinions, but not to their facts.

But it is not only those with current needs who will be exposed by widespread use of HSAs. Healthy individuals purchasing the high-deductible plans will find that they do not provide adequate financial protection should they later have major health care needs. It is important to realize that the traditional high-deductible indemnity plans essentially no longer exist, as indicated on the HealthInsurance.com website. No longer can you buy a plan that has only a 20% coinsurance for all services, and full, 100% coverage after an out-of-pocket maximum.

Currently available and HSA-qualified high-deductible plans are primarily PPO plans with restricted benefits, significant coinsurance, and limited provider lists. Current trends suggest that these restrictions will increase as efforts are made to keep the premiums affordable.

The IRS notice confirms that the maximum out-of-pocket expense of $5000 for individuals and $10,000 for families applies only to care provided under the plan. There is no stop-loss protection for care obtained from non-contracted physicians and hospitals, not to mention the very heavy financial penalties that are assessed for receiving care out of the network of providers.

Thus the only individuals who will be exposed to financial disaster are those with health care needs who are left with the death spiral of premiums, or those with needs who will find that their high-deductible PPO will leave them financially exposed. But those of us who are healthy and who will remain healthy will do just fine. Just don’t get sick.

At least the WSJ editors were correct when they facetiously noted that I was
not calm in my response to Title XII, the HSA provision of the Medicare bill. My histrionics are still applicable:

“CONTACT YOUR REPRESENTATIVES AND SENATORS IMMEDIATELY AND DEMAND THE URGENT REPEAL OF TITLE XII OF THE MEDICARE ACT!”

Don McCanne

Is Dr. Dean's prescription a placebo?

The Washington Post
December 21, 2003
Dean’s Care For All, Built Part by Part
By Ceci Connolly

(In 1994, Vermont Governor Howard) Dean, a doctor by training, would be the nation’s first governor to guarantee health coverage to every state resident. And he would do it in a single legislative session, with one enormous bill.

It was ambitious, bold — and an utter failure.

But it wasn’t the end. Like a pragmatic physician who tries a new therapy when the first fails, Dean devoted much of the next decade to smaller, incremental changes aimed at filling the state’s health care gaps.

It was a slower strategy, but by the close of his tenure, Dean came very close to achieving universal health coverage. Vermont now has one of the nation’s highest rates of health insurance coverage, providing care to virtually every child and more than 90 percent of adults. The national average is 83.7 percent.

As some Democratic presidential rivals are quick to note, Dean’s embrace of
balanced budgets led him to flirt with the Medicare-reduction plans of then-U.S. House Speaker Newt Gingrich (R-Ga.), and Dean sometimes trimmed his own state health programs.

These opponents also said that his policies have exacerbated the financial problems for Vermont hospitals, and despite Dean’s efforts to expand health
care coverage, there remains a yawning insurance gap for residents ages 18
to 29. Most important, Dean’s heavy emphasis on government-run programs,
with their low reimbursement rates, has saddled the business community with
higher costs, according to some health care officials.

“Gov. Howard Dean has presided over a constant expansion in government health programs, without a commensurate increase in funding,” the Burlington Free Press editorialized in December 2000.

Another criticism of Dean’s health care record is that his heavy reliance on
government programs hurt the private sector. Because government reimbursement rates are so low, doctors and hospitals in Vermont have been forced to charge more to private clients — individuals and businesses — to make up the difference. As Dean encouraged families to enroll their children in Dr.Dynasaur, corporate insurance pools were left with a larger proportion of high-risk, more expensive adults.

Dean’s tactics and style could inflame tensions, lawmakers said. On several
occasions, he proposed trimming the very health benefits he instituted, including dental, foot and eye care for Vermont’s low- and moderate-income adults. He fiercely defends this approach.

“I promised the people of Vermont I would not take one person off the program,” he said. “So we did eliminate certain benefits. But that’s better than cutting people.”

http://www.washingtonpost.com/ac2/wp-dyn?pagename=article&node=&contentId=A17383-2003Dec20¬Found=true

Comment: The current emphasis on reducing the numbers of uninsured has created an explosion in the rate of under-insurance. Reducing benefits, increasing cost sharing, inequitably funding risk pools, shifting public program costs to providers which drives up fees for private payers, concentrating high-cost patients in separate risk pools making the premiums unaffordable, are only a few of the problems exacerbated by implementing a policy of incremental expansions of program enrollment without ensuring adequate funding of those programs.

Being insured may not mean much if care remains unaffordable because necessary benefits are not covered or the out-of-pocket expenses are too high. But limited insurance is better than none at all. Is there an alternative? Of course. Comprehensive coverage can be provided for everyone at no significant increase in cost if we were to eliminate the administrative inefficiencies of our multi-payer and non-payer system, and establish a single, universal health program.

Dr. Dean initially supported single payer reform but found that it wasn’t politically feasible. He then demonstrated that a pragmatic, incremental approach was feasible, even though it falls short on many goals. Dr.Dean has said that, as president, he would sign a single payer bill if it made it to his desk. But whoever is president, a single payer bill will never pass Congress without overwhelming public support. That won’t happen until the public really understands the various options. We have a lot of work to do.

There is risk for us. We may discover that the real reason for the lack of reform is that the United States is a nation that does, in fact, uniquely reject egalitarianism. Are you prepared to accept that possibility?

Is Dr. Dean’s prescription a placebo?

The Washington Post
December 21, 2003
Dean’s Care For All, Built Part by Part
By Ceci Connolly

It was ambitious, bold — and an utter failure.

“Gov. Howard Dean has presided over a constant expansion in government health programs, without a commensurate increase in funding,” the Burlington Free Press editorialized in December 2000.

“I promised the people of Vermont I would not take one person off the program,” he said. “So we did eliminate certain benefits. But that’s better than cutting people.”

http://www.washingtonpost.com/ac2/wp-dyn?pagename=article&node=&contentId=A17383-2003Dec20¬Found=true

President Bush's "Ownership Society"

The New York Times
December 20, 2003
The Ownership Society
By David Brooks

In his State of the Union address, the president will announce measures to foster job creation. In the meantime, he is talking about what he calls the Ownership Society.

This is a bundle of proposals that treat workers as self-reliant pioneers who rise through several employers and careers. To thrive, these pioneers need survival tools. They need to own their own capital reserves, their own retraining programs, their own pensions and their own health insurance.

President Bush has a proposal to combine and simplify the confusing morass
of government savings programs and give individuals greater control over how
they want to spend their tax-sheltered savings. Administration officials hope, in a second term, to let individuals control part of their Social Security pensions and perhaps even their medical savings accounts.

Talking with staff, Bush emphasizes that he wants to use these policies to move from an “anything-goes culture” to a “responsibility culture.” By giving individuals control of their own retraining, their own savings and their own homes, he hopes to inculcate self-reliance, industriousness and responsibility.

Comment: Implicit in the shift to a “responsibility culture” through the establishment of the “Ownership Society” is the principle that opportunity is available to all. But universal opportunity means that we must have employment opportunities, living wages, affordable housing, affordable health insurance, enough disposable income to fund retirement accounts, and all of the other affordable opportunities that will make us “self-reliant pioneers.”

It is safe to say that for far too many of us, those opportunities do not exist. It is highly unlikely that the individuals without opportunities can create them by mere volition using their pioneering spirit. These deeply-rooted societal problems cannot be solved by merely praising the virtues of a utopian Ownership Society. These problems require a component of public policies and public programs to give us the “survival tools” needed to accomplish these goals.

We can use health care as an example. Just as mega-corporations are jointly
owned by shareholders, a universal program of health insurance can be jointly owned by the citizens. That would provide everyone with the survival tool for health care.

We can approach the goals of a utopian Ownership Society providing that we
properly balance private and public ownership by adopting public policies
that will accomplish these goals. President Bush needs to show us real policies that will provide all citizens with the survival tools they need to “own their own capital reserves, their own retraining programs, their own pensions and their own health insurance.” But to be effective, some of these will require joint public ownership within our Ownership Society.

President Bush’s “Ownership Society”

The New York Times
December 20, 2003
The Ownership Society
By David Brooks

In his State of the Union address, the president will announce measures to foster job creation. In the meantime, he is talking about what he calls the Ownership Society.

"Consumering" rewards healthy

Benemax (A Benefit Management Company)
Consumer Driven Health Care (CDHC)
CDHC presentation slides (excerpts)

“Unleashing the power of free market economics on the healthcare
industry”

Why CDHC: Consumering
Patients shop for quality & price
Providers compete for patient traffic
Patients subject treatment options to cost/benefit analysis

What a CDHC plan does
Varies member cost based on health care behavior
Rewards members with below median health care costs

http://www.benemax.com/presentation-cdhc/cdhc1.html

The American Heritage Dictionary of the English Language
Fourth Edition

“Consumering”: No documents match the query

http://www.bartleby.com/61/

Comment: Although “consumering” apparently rewards patients “with below
median health care costs,” conversely it seems to punish patients with above median health care costs. The opposite of insurance, “consumering” protects the healthy from the costs of those with legitimate health care needs, and further punishes the sick by adding the financial burden of accessing health care.

“Consumering” doesn’t seem to be a very good idea. Let’s not add it to
our dictionaries.

Society Scorns the Oldest, excludes the Youngest and takes individuality to extremes

Le Monde diplomatique
December 2003

‘SOCIETY SCORNS THE OLDEST, EXCLUDES THE YOUNGEST AND TAKES INDIVIDUALITY TO EXTREMES’

France: health as a commodity

French healthcare leads the world, but the government is about to change the financing of the system from public funding to private insurance. This threatens not only the future well-being of the French but the basis of the nation’s social contract.
By MARTINE BULARD

WILL the French social security system soon be just a memory? Using this year’s deficit forecasts, the government is tweaking its arguments to justify structural reform, which has been officially postponed until early 2005. But measures already taken have set the tone, including cuts in reimbursements, a rise in the daily hospital charge and hospital bed closures. This is a traditional package in most developed countries.

Public health systems are being challenged everywhere, whether they are based on employment-related resources and co-run by employers and employees (the Bismarck system in Germany and the Netherlands), state-run and funded by taxation (the Beveridge system in the United Kingdom, Italy and Sweden), or a mixed model (as in France). Inequalities are soaring but so are deficits, although health-benefit cuts were supposed to plug the financial gaps.

The social security deficit curve generally shadows the unemployment curve. In France, if contribution revenue had grown by 6% in 2002 as it did in 2001, there would be no gap. But slumping growth reduces contribution revenue and deepens deficits, prompting austerity programmes that cause falling consumption, stifling growth, thus reducing social security contributions and so on. The pit is bottomless.

This should prompt questions over remedial cuts, which are about as useful as bloodletting. But there is an ideological barrier here. True, there is no global conspiracy, no hidden mastermind imposing the same solution everywhere. However, there are very real pressure groups with a direct interest in the health-benefit bonanza – $3.5 trillion worldwide. Their lobbying targets are international organisations that claim to be neutral, such as the World Bank with its influential 1994 report that explained how social spending would become an unbearable burden for nations and cause lasting changes to security systems (1). The World Trade Organisation (WTO) provided the general agreement on trade in services, a byword for privatisation.

These ideas circulate freely because the experts involved easily change hats. An author of the World Bank report, Estelle James, joined President George Bush Jr’s team to handle privatising health benefits (2). In France the health minister, Jean-François Mattei, and the social affairs minister, François Fillon, asked two private-sector figures – François Chadelat, a senior executive with the insurer Axa, and Alain Coulomb, representing private hospitals – to propose ways to clarify the roles of public and private sectors. Transfers are two-way: Gilles Johanet, director of France’s national social security fund (CNAM), left to run the health and collective insurance division of giant AGF.

The solutions stay the same: cuts in collective spending and the promotion of personal initiative, deemed to yield better performance. In the name of this principle, accounting-driven regulation was introduced in the mid-1980s, promising that by cutting doctors, pharmacies and hospital beds, there would be fewer patients or, at least, lower spending. French governments have tried to achieve this for 25 years, capping the number of doctors and nursing staff. The operation has been more successful than expected. From 2010 more doctors will retire from medicine than will enter it, although public hospitals are already 3,500 doctors short, despite 9,000 foreign practitioners, underpaid and with insecure status.

Public hospitals have lost more beds – 35,352 in seven years- than private ones (18,475). Small local hospitals that could treat common conditions and distribute patients have closed. They would have been useful during this summer’s heatwave and could ease the strain on casualty departments in large towns. Patients must sometimes travel long distances to hospitals that, while superbly equipped, are unsuited to treating ordinary cases. Maternity hospitals have been shut down in the name of safety and women redirected to large complexes often too sophisticated to deal with routine pregnancies: yet there is astonishment at the rising proportion of reimbursements for transport costs.

Spending rises steeply with no reduction in inequalities.The lack of joint regulation in the assignment of doctors is leaving areas unserved: Picardie has only 110 specialists for 100,000 inhabitants compared to 220 in Provence-Alpes-Côte-d’Azur, 234 in Ile-de-France and an average 169 across the whole European Union.

France still ranks first in the world for healthcare, according to the World Health Organisation. Doctors do not yet have to keep patients waiting a year for hip or heart operations, as they do in Britain, or 208 days for a cataract operation, as in Finland, or 128 days as in Denmark (3).

But there are danger signs: in Ile-de-France 60% of patients wait at least two weeks for a magnetic resonance imaging appointment; the experts say that time limit should not be exceeded (4). “The quotas for medical equipment are ridiculous,” says Professor Bernard Debré. “France ranks last in the world for the number of MRIs performed, behind Turkey” (5). People in business, political and media circles have contacts and are unaffected by this.

The lack of preventive medicine, and the way that it is being sidelined where it had been developed in schools and businesses, deepens inequalities further. According to the French research centre for health economics Credes, 14.7% of French people have given up healthcare for financial reasons; 30% of this group are jobless. Despite the creation of Universal health insurance (known in France as CMU), between a quarter and a third of those entitled to it have not been
able to afford it. Working-class households spend half as much as managers’ families on specialist consultations, but twice as much in hospital costs. They seek care later, which costs more. The authors of Inégalités sociales de santé say that 10,000 premature deaths a year could be avoided if blue- and white-collar workers had the same mortality rate as senior managers (6).

The measures in the pipeline will, instead of tackling these injustices, steepen the slide. In 2001 the French business confederation Medef presented a full report on its version of social security: a US-style system with minimal, tax-funded care provision for the poorest and top-up insurance for the rest, as individual or group pol icies provided by mutual societies and insurers. Yet we know the economic outcome of this. The US, the land of optional insurance and always the example quoted, holds the record for health spending. In 2001 the proportion was 13.9% of wealth created, compared to 10.7% in Germany, 9.5% in France and 7.5% in Finland, where free care is the rule (7); anyway, 41 million Americans have no health cover and the problem is now affecting the middle classes. In 2001, according to the New York Times, 1.4 million people, 800,000 of whom earned more than $75,000, lost their health insurance (8). Rising unemployment was a factor but the main cause was insurance premiums, which have soared (9). Patients who want to be reimbursed cannot choose their doctors, who cannot practise as they would like. “Managed care has become the de facto national health policy of the US” (10), writes George Anders, citing paediatricians; insurance companies have forced them to shorten their consultations by some 10 minutes.

The French government, inspired by this model, is seeking to redefine the areas covered by the public and private sectors. Jacques Barrot, of the Union for the Presidential Majority coalition, explains: “We need to distinguish between small risks and heavy risks. The latter must be covered by compulsory insurance and the other risks by top-up or voluntary insurance from mutual societies or private insurers” (11). Such a distinction is medically absurd (a small risk can conceal a serious disease), socially unjust (only the rich would be able to look after themselves) and economically costly (the later care is sought, the more is spent). Chadelat’s report (12), the basis for the government’s work, is written in the same spirit. In proposing a major change in the health cover mechanism in France as it has existed since 1945, he calls for “a basket of care” (minimum care provision with no precise definition), which would be co-funded by the general social-security scheme (compulsory health insurance) and by top-up insurance, mainly from mutual societies. These sources would supply 80% of funds, with the rest covered by extra top-up insurance.

But top-up cover does not exist for some part-time employees and expires when workers lose their jobs or retire. Only 52% of over-65s have it. Moreover regulation of mutual societies is now similar to that of insurers and premiums are likely to grow. Alongside this new share-out, the contributions payable by employers and employees would be cut; this would cost the social security system an estimated ?2bn per full year, more than 2% of its resources.

Total health commoditisation would damage society. The social security system is about more than health and pensions: it shapes the contours of social organisation. It gives those without capital some independence in bad times. It allows people to do without charity or welfare and gain entry to a system of rights. Social security made a leap forward, gradually freeing social relations from the market. To revert to the uncertainty of the individual contract and the madness of the financial markets would be a leap backward. Many young people and women, insecure and with no top-up insurance, but too “wealthy” to qualify for CMU, would have to agree to live in permanent anxiety about the future, unable to make positive plans. The old would have no right to an untroubled retirement. The economist Alain Cotta, noting that 70% of healthcare costs are incurred in the last six months of life, proposed in all seriousness “self-regulation organised by society [which would create] a social function: putting people to death” (13) and a cut-off of healthcare for anyone over 90, which would codify social euthanasia.

A society that scorns the oldest, excludes the youngest and takes individuality to extremes is far from inevitable. Reforms are essential, but also a recognition that health spending will continue to grow. In all countries rising standards of living result in greater demand for care – and for culture and leisure. Technological progress increases the cost of treatment; people live longer and need greater medical supervision; the advent of serious diseases (Aids) or their growing incidence (cancer) demands extra funding. In France the birth rate is rising. In 2002 midwifery costs were one of the highest increases, 11.8%, in social security reimbursements.

In France and other developed countries the share of national wealth devoted to health will rise. This is no great drama or insurmountable hurdle, as long as the debate sticks to genuine issues and a new architecture is built based on new financial resources. Health spending underpins growth. It generates qualified jobs for care provision direct to consumers in hospitals and laboratories, research and industry. Promoting a real prevention policy, especially in schools and the workplace, would also create jobs. Throughout the developed world, generating qualified employment is the best way to increase jobs: in France 100,000 more jobs would mean an extra ?1bn in contributions.

That is why contributions must remain linked to business wealth creation and not be replaced, as some advocate, by the contribution sociale généralisée (CSG), the universal social security tax introduced in 1991 by the Socialist party. The CSG was initially justified as being a tax on capital revenue, not being deducted from salaries; in fact 93% of it is taken from salaries. The exemption of French businesses from contributions, with no positive requirements in return, is freeing masses of money, much of which flows into stock markets. Exemptions jumped from ?1.3bn in 1991 to ?8.8bn in 2001, more than that year’s social security deficit. Exemption cutbacks would allow proper funding reform: use VAT and not salaries as a funding source and adjust contributions to favour companies that created properly-paid and qualified jobs. This would add value to labour without intensifying it or abolishing national holidays.

Aspects of French healthcare need an overhaul, especially the introduction of a more preventive system. Prevention currently costs 2.3% of total spending. Improving it would cost slightly more initially but would soon generate savings. Oral-hygiene pilot schemes in schools in the Seine Saint-Denis département have reduced tooth decay and costly treatments. Mutual societies have conducted other positive experiments.

To make the healthcare system more efficient and economical, the role of drugs needs to be re-evaluated. France is not the world’s biggest consumer, ranking below Sweden, the US, Canada, Finland, Australia and Ireland, but above Germany and Italy (although the French do seem to take the most anti-depressants) (14). Pharmaceutical companies have too much power in the decision-making process and the government has enabled them to fix the price of new drugs. To escape this, transparent and independent commissions, with doctors and representatives of the social security system, mutual societies and patients, should set prices and favour generic products, at present only 10% of French prescriptions compared to 28% in Germany.

We need to redefine the doctor’s role. There is no question of reviewing patients’ freedom of choice and practitioners’ freedom to prescribe. But we must recognise the system’s failings: 14% of GPs prescribe 50% of reimbursed medicines; 40% of specialists and 50% of dentists charge more than the basic rate set by the social-security scheme. Doctors in rural and problem areas struggle to make ends meet at ?20 a consultation, but others do well – radiologists earn an
average of ?14,200 a month gross.

Continuing vocational training remains marginal. Philippe Houcarde, a health economics specialist, advocates more active control – stopping patients from specialist-hopping and limiting doctors’ prescriptions. But he primarily recommends encouraging new forms of practice and pay: different rates according to the scope of the diagnosis and the time spent on it, or flat fees according to the service provided; group practices and experimental clinics open evenings and weekends, run by a rota of doctors who provide minor treatment and refer patients to specialists as necessary, thus absorbing patients from hospital casualty departments.

The system cannot be re-energised to boost performance and save money without democracy. French deputies set annual spending standards with no idea of medical consequences. The genesis of disease and the evolution of pathologies are scarcely studied. The managers of the social security system – unions and employers – are accountable to no one; elections to choose them were suspended in 1983. Patients’ associations are excluded. The system combines state control and bureaucratisation.

Pierre Laroque, father of the French social security system, believed that the creation of universal insurance meant combining an economic policy geared to full employment, a health infrastructure and medical organisation policy that aimed for prevention first and treatment second, and a revenue distribution policy that tended to modify the blind distribution of economic mechanisms (15). His mighty ambition, soon forgotten, is more topical than ever: it is about building a different health system.

Rather than leave all this to the market, it would be better to reduce the insecurity of daily life and build on the solidarity – between young and old, healthy and sick, the single and families – that is at the heart of the social security system.
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(1) “Averting the old age crisis”, World Bank, Washington DC, 1994. Also La régulation du système de santé, Conseil d’analyse économique, La documentation française, Paris, 2000.

(2) Dean Baker, “The World Bank’s attacks on social security”, Centre for Economic and Policy Research, 7 August 2001, Washington.

(3) “Les systèmes de santé danois, suédois et finlandais”, Etudes et Résultats, n° 214, Direction de la recherche et des études de l’évaluation et des statistiques, January 2003, Paris.

(4) “Les trajectoires des patients en Ile de France”, Questions d’économie de la santé, n° 31, July 2000, Paris.

(5) “Comment soigner un tel malade”, France soir, 2 December 2002.

(6) Annette Leclerc, Didier Fassin, Hélène Grandjean, Monique Kaminski and Thierry Lang, dir, Inégalités sociales de santé, La Découverte/Inserm, Paris, 2000.

(7) “Health data 2003”, second edition, Organisation for Economic Cooperation and Development, July 2003.

(8) “Problem of lost health benefits is reaching into the middle class,” New York Times, 25 November 2002. Available on Commondreams.org.

(9) Milt Freudenheim, “Health benefit costs soar in US,” International Herald Tribune, Paris, 11 September 2003.

(10) “The medicine in our future,” New York Review of Books, 12 June 1997. NYROB’s archives are on subscription.

(11) La Tribune, Paris, 28 October 2002.

(12) “La répartition des interventions entre les assurances obligatoires et complémentaires”, Commission des comptes de la Sécurité sociale, Paris, July 2003.

(13) Journal du Dimanche, Paris, 7 September 2003.

(14) Health Data 2003, op cit.

(15) Henry C Galant, Histoire politique de la Sécurité
sociale française – 1945-1952, Librairie Armand Colin, 1955.

Translated by Paul Jones
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http://MondeDiplo.com/2003/12/13socialsecurity

The Prescription drug battle with Canada

The Pacific Research Institute presents ‘The Prescription drug battle with Canada’ a Panel Debate on Tuesday, January 27, 2004.

Please get more information by going to their website
http://www.pacificresearch.org/events/index.html

“Consumering” rewards healthy