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What is ‘integrated care’ and do we want it?

What is ‘integrated care’ and do we want it?

Rethinking Integrated Care: A Systematic Hermeneutic Review of the Literature on Integrated Care Strategies and Concepts

By Gemma Hughes, Sara E. Shaw, Trisha Greenhalgh
The Milbank Quarterly, May 20, 2020

Abstract

Context: Integrated care is a broad concept, used to describe a connected set of clinical, organizational, and policy changes aimed at improving service efficiency, patient experience, and outcomes. Despite examples of successful integrated care systems, evidence for consistent and reproducible benefits remains elusive. We sought to inform policy and practice by conducting a systematic hermeneutic review of literature covering integrated care strategies and concepts.

Methods: We used an emergent search strategy to identify 71 sources that considered what integrated care means and/or tested models of integrated care. Our analysis entailed (1) comparison of strategies and concepts of integrated care, (2) tracing common story lines across multiple sources, (3) developing a taxonomy of literature, and (4) generating a novel interpretation of the heterogeneous strategies and concepts of integrated care.

Findings: We identified four perspectives on integrated care: patients’ perspectives, organizational strategies and policies, conceptual models, and theoretical and critical analysis. We subdivided the strategies into four framings of how integrated care manifests and is understood to effect change. Common across empirical and conceptual work was a concern with unity in the face of fragmentation as well as the development and application of similar methods to achieve this unity. However, integrated care programs did not necessarily lead to the changes intended in experiences and outcomes. We attribute this gap between expectations and results, in part, to significant misalignment between the aspiration for unity underpinning conceptual models on the one hand and the multiplicity of practical application of strategies to integrate care on the other.

Conclusions: Those looking for universal answers to narrow questions about whether integrated care “works” are likely to remain disappointed. Models of integrated care need to be valued for their heuristic rather than predictive powers, and integration understood as emerging from particular as well as common contexts.

From the Introduction

A guiding principle for system redesign is integrated care. Integrated care refers to both the methods that might be used to organize, fund, and deliver health and related services and the interrelated goals of better outcomes, experiences, and use of resources. Integrated care has been studied in various ways—for example, as an organizational and social process, as an indicator of health system effectiveness, and for its effects, such as economic impact. The result is a heterogeneous body of literature with the term used by different authors to mean different things. Most espouse “patient‐centered” goals and values. Few dispute the principle of integration. (Who would want care that is not integrated?)

To date, consistent benefits from integrated care programs have proved elusive. Despite evidence of some aspects of improvement in certain settings for certain people, expectations that integrated care programs will improve outcomes and reduce health service utilization are often disappointed.

From the Discussion

The search for integrated care is a search for unity. This applies both to efforts to integrate patient care, services, and organizations and to scholarly work to create unified conceptual models. However, we found two key tensions across the literature that undermine the idea of integrated care as a unified concept. First, we found that “integrated care” was not one empirical phenomenon; rather, it covered a multiplicity of objects, strategies, and aims. Practical efforts to integrate care were concerned with creating unity of a great variety of objects: patient care and experience, multidisciplinary and interorganizational working, and health care systems. “Integrated care” included overlapping, interrelated, and, at times, conflicting strategies and experiences. Moreover, integration was pursued for a variety of ends (eg, to both improve patient experience and to reduce hospital admissions) and meant different things to different people. Patients, service providers, and policymakers had different ideas about, and different experiences of, integrated care.

Second, we found that conceptual models of integrated care assumed alignment of patient and system perspectives and of multiple strategies into a coherent, decontextualized whole. However, the range of framings provided by scholars bringing social theory and critical analysis to the study of integrated care undermines the normative, and often deterministic, frameworks provided by unified models.

Integrated care programs are contextually shaped but have common logics. Normative models of integrated care can therefore be of heuristic value (for example, in accounting for features of successful programs), but they will inherently fall short of accounting for the intricacies of different contexts and processes. The range of theoretical framings found in this review used to analyze integrated care preclude the creation of a single explanatory model. Integrated care can more usefully be studied and understood as comprising an emergent set of practices intrinsically shaped by contextual factors than as an intervention that will achieve a predetermined set of outcomes.

https://onlinelibrary.wiley.com…

Comment:

By Don McCanne, M.D.

The policy community and the medical-industrial complex seem to be fixated on business models of reform rather than patient service models. “Integrated care” seems to be a common theme of theirs, though this Milbank Quarterly report indicates that there is little agreement on precisely what integrated care means.

As the authors state, “Who would want care that is not integrated?” But Kaiser Permanente as an integrated delivery system is quite different from an accountable care organization to which patients do not even realize that they are nominally assigned. Hospitals purchasing physician practices is a different kind of integration than when large investor-owned insurers assume control of portions of the delivery system. Clinics coordinating with food, housing, and transportation services is another form of integration. Private Medicare Advantage plans integrated with contracted vendors is quite different from traditional Medicare that is integrated with almost the entire health care delivery system. And so on.

The greatest problem in health care today is that, in spite of spending $4 trillion, far too many are unable to access the care they need because of the financial barriers that result from the design of our health care financing system. The solution is simple. Fix the problems that are inherent in our existing Medicare program, expand it to include everyone, and fund it with equitable, progressive taxes that will make it affordable for each of us. If you want to call that an integrated financing system then go ahead, but do not let the business interests expand control through their integrated entities that are designed primarily for business success rather than for patient service.

The Milbank Quarterly article is an open access article. You may want to read the full article as it can assist you in rethinking integrated care. Let’s get it right for the patients, not the plutocrats.

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The other epidemic: Lack of health insurance for all Americans

Time to ensure coverage for everyone

By Jessica Schorr Saxe, M.D.
The Charlotte Post, May 27, 2020

Rapidly and predictably following the onset of the pandemic, many Americans are victims of an epidemic of uninsurance, which will also predictably lead to suffering and death.

This loss of insurance is a uniquely American epidemic, not a pandemic. While millions of Americans risk losing health insurance if they lose their jobs, citizens of other developed countries, where insurance is not linked to jobs, do not.

Nearly 50 million people in families where someone lost a job in March or April will lose employer-sponsored insurance. While some will be able to retain coverage through another family member, almost 27 million will be uninsured. In North Carolina, at least half a million people are expected to lose their insurance. While some will be eligible for Medicaid or Affordable Care Act policy subsidies, nearly 200,000 will remain uninsured and join the half million already in the coverage gap.

And, just as the pandemic itself has disproportionately affected African Americans and Latinos with higher rates of infection and death, so, too, has the resulting unemployment.

Even those eligible for other insurance will find the transition disruptive. Perhaps you have just lost your job or can imagine doing so. You already have stresses of lost income, uncertainty, and waits that feel interminable to get unemployment insurance. In addition, you will need to sort out what health insurance you are eligible for, jump bureaucratic hurdles to apply, and then, if you are successful, navigate different networks and new providers.

You may experience interruptions in needed care or medications. And even if you are eligible, you may be unable to afford premiums when you have no income and may still find yourself uninsured.

The pandemic has unmasked the abject failure of a system based on employer-sponsored insurance, which, like a fair-weather friend, vanishes when we need it most.

Measures taken so far are woefully inadequate. While both the Families First Coronavirus Response Act and the CARES Act covered some testing, they did not cover all. In the words of the Kaiser Family Foundation, “COVID Tests Are Free, Except When They’re Not.” Treatment has not been covered for COVID patients, let alone those unemployed who are suffering from something else.

HR 6906 and S 3790, introduced to Congress on May 15, is the best short-term solution to address the uninsurance epidemic. It would provide comprehensive coverage without co-pays for both the uninsured through improved Medicare and for the insured by subsidizing their insurance coverage. Other features include banning surprise billing, controlling prescription drug prices, and forbidding insurance companies from decreasing coverage.

This bill would give Americans the best chance of protecting their health at this difficult time. In addition to covering diagnosis and treatment of coronavirus, thus helping to prevent spread to the rest of us, it would also cover management of diabetes, heart disease, and other critical health conditions, as well as preventive care.

A recent survey of voters showed that about three out of four, including over half of Republicans, support this approach. In the long run, we need a healthcare system that serves us all.

Dr. Jessica Schorr Saxe is a retired family physician in Charlotte and chair of Health Care Justice—NC.

http://www.thecharlottepost.com…

Bailout funds go to the wealthiest hospitals

Wealthiest Hospitals Got Billions in Bailout for Struggling Health Providers

By Jesse Drucker, Jessica Silver-Greenberg and Sarah Kliff
The New York Times, May 25, 2020

A multibillion-dollar institution in the Seattle area invests in hedge funds, runs a pair of venture capital funds and works with elite private equity firms like the Carlyle Group.

But it is not just another deep-pocketed investor hunting for high returns. It is the Providence Health System, one of the country’s largest and richest hospital chains. It is sitting on nearly $12 billion in cash, which it invests, Wall Street-style, in a good year generating more than $1 billion in profits.

And this spring, Providence received at least $509 million in government funds, one of many wealthy beneficiaries of a federal program that is supposed to prevent health care providers from capsizing during the coronavirus pandemic.

So far, the riches are flowing in large part to hospitals that had already built up deep financial reserves to help them withstand an economic storm. Smaller, poorer hospitals are receiving tiny amounts of federal aid by comparison.

After the CARES Act was passed in March, hospital industry lobbyists reached out to senior Health and Human Services officials to discuss how the money would be distributed.

Representatives of the American Hospital Association, a lobbying group for the country’s largest hospitals, communicated with Alex M. Azar II, the department secretary, and Eric Hargan, the deputy secretary overseeing the funds, said Tom Nickels, a lobbyist for the group. Chip Kahn, president of the Federation of American Hospitals, which lobbies on behalf of for-profit hospitals, said he, too, had frequent discussions with the agency.

The department then devised formulas to quickly dispense tens of billions of dollars to thousands of hospitals — and those formulas favored large, wealthy institutions.

Hospitals that serve a greater proportion of wealthier, privately insured patients got twice as much relief as those focused on low-income patients with Medicaid or no coverage at all, according to a study this month by the Kaiser Family Foundation.

https://www.nytimes.com…

Distribution of CARES Act Funding Among Hospitals

By Karyn Schwartz
KFF, May 13, 2020

The Department of Health and Human Services (HHS) has now begun distributing $72.4 billion of the $175 billion allocated for grants to health care providers in the Coronavirus Aid, Relief, and Economic Security (CARES) Act and the Paycheck Protection Program and Health Care Enhancement Act.

Our analysis shows that the size of the relief fund grants varies dramatically per hospital bed based on a hospital’s payor mix. Hospitals with the lowest share of private insurance revenue received less than half as much funding for each hospital bed compared to the hospitals with the greatest share of revenue from private insurance. These hospitals’ large share of private reimbursement may be due either to having more patients with private insurance or charging relatively high rates to private insurers or a combination of those two factors. All things being equal, hospitals with more market power can command higher reimbursement rates from private insurers and therefore received a larger share of the grant funds under the formula HHS used.

https://www.kff.org…

Comment:

By Don McCanne, M.D.

Compared to our highly dysfunctional, fragmented system of financing health care, heavily dependent on private health insurance, a single payer model of an improved Medicare program that covered everyone would be vastly superior, being much more efficient, effective, and equitable than our current system.

So now that we have a catastrophic pandemic that mandates a response by government, how does our government that favors the private sector respond? Do they support expanding Medicare to fill in the deficiencies during this crisis? No. Instead they dispense the bulk of their grants to wealthy hospitals with more market power that receive much of their revenues from private insurers that pay much higher rates than the government programs. And financially precarious hospitals that receive much lower revenues because of their commitment to patients on government plans or who are uninsured, they are granted…a pittance.

If we believe that health care should be made affordable and accessible for everyone, the only way we can do that is by establishing a universal government program, ideally single payer Medicare for All. But in a representative democracy, that means that we, the people, must do our part in electing legislative and administrative stewards who are committed to such a program. Obviously over the last century we have failed to do so. Isn’t it about time we shaped up?

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Health care reform due

By Johnathon Ross, M.D., M.P.H.
The (Toledo, Ohio) Blade, May 25, 2020

The Partnership for America’s Health Care Future is a dark-money group mainly funded by health insurance and pharmaceutical companies whose profits are most threatened by health care reform. They are spending of millions of dollars running ads against “Medicare for All” and public option-type reform. Sadly, the American Hospital Association is participating and financially supporting this shameful anti-reform effort.

Improved expanded Medicare for all is supported by the majority of Americans. The American Medical Association and the American College of Radiology recently left the partnership. The AMA left under pressure after nearly losing a policy vote promoted by student members who support Medicare for All.

Our broken health system wastes more than $600 billion on insurance overhead and profits and leaves tens of millions of Americans without health coverage. As the coronavirus pandemic spreads, tens of millions more are losing their jobs and their health insurance. A Medicare-for-All system would save the $600 billion and provide seamless cradle-to-grave coverage without co-pays, deductibles, or narrow provider networks covering all of us, including the uninsured and unemployed in good times and bad.

The AHA cannot claim to represent struggling hospitals while opposing single-payer Medicare for All. Medicare for All would completely fund hospitals through annual publicly accountable global budgets based on community health needs. Medicare for All would provide a financial lifeline to rural and safety net hospitals who care for greater numbers of uninsured and under-insured patients.

Our hospitals should not be wasting precious resources advertising against universal health coverage. Doctors and nurses are demanding that the AHA immediately leave the anti-reform PFAHCF. Money spent advertising against reform should be spent caring for patients and protecting our caregivers struggling against the pandemic.

Dr. Johnathon Ross is a past president of Physicians for a National Health Program.

https://www.toledoblade.com…

2020 Milliman Medical Index, with a new twist

By Chris Girod, Paul Houchens, Dave Liner, Andrew Naugle, Doug Norris, Scott Weltz
Milliman Research Report, May 2020

Executive summary

In 2020, the cost of healthcare for a hypothetical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan is $28,653, according to the Milliman Medical Index (MMI).

Key findings of the 2020 MMI include:

Cost increases have continued to be mostly “moderate.” For an average person, healthcare cost grew by approximately 4.1% from 2019 to 2020. That rate is roughly consistent with rates over the past five years, and is definitely moderate relative to rates from 10 years ago, which were twice as high. Nevertheless, the cost increases continue to outpace gross domestic product (GDP) growth, which is roughly half the rate of healthcare cost growth. Recently, hospital costs have taken center stage, growing more quickly than costs for other services, climbing approximately 15% over the past three years, versus 10% for all other services combined.

COVID-19 will have big impacts on healthcare costs in 2020. That much is certain. However, the impacts will manifest as some very big cost increases (for direct COVID-19 care), and some very big cost decreases (for deferred and forgone services). On average, the net outcome is still highly uncertain. We know, for example, that COVID-19 testing and treatment costs are new in 2020. However, these amounts may be dwarfed by the spending reductions resulting from deferrals of care. At this time, there is tremendous uncertainty around the net effect on costs. Therefore, in this year’s MMI report we have not made explicit adjustments to our 2020 cost projections to reflect COVID-19 impacts.

For the first time, this year’s report looks at the effects of managed care on costs. Since its first edition in 2005, the MMI has focused on “what is”—namely, what employer-sponsored healthcare costs are on average nationwide. Very little time has been spent discussing “what could be”—what could healthcare costs be under an ideal system? Milliman’s research indicates that effective use of managed care principles could reduce overall healthcare costs for the MMI family by approximately 25%, which would lower the family’s annual costs from $28,653 to $21,490.

https://milliman-cdn.azureedge.net…

Comment:

By Don McCanne, M.D.

Just a reminder of what the Milliman Medical Index (MMI) is: It is the cost of health care for a hypothetical American family of four covered by an average employer-sponsored preferred provider organization (PPO) plan. For 2020 that cost is $28,653 per family.

Of great significance, the MMI continues to increase at twice the rate of the growth in our gross domestic product (GDP). Thus excessive health care cost growth has not been contained by the provisions of the Affordable Care Act, nor by the various other tools such as the Medicare Shared Savings Program (MSSP) and the alternative payment models (APMs) designed to replace volume with value, such as accountable care organizations (ACO), and merit-based incentive payment system (MIPS). Particularly disappointing have been the consumer-directed approaches of increasing deductibles and other cost sharing since not only have they failed to control costs but they have also created unnecessary financial hardship for far too many individuals and families who have greater health care requirements.

New in this year’s MMI report: Milliman estimates that managed care principles could be used to reduce health care costs by 25% – from annual family costs of $28,653 down to annual costs of $21,490. But other than stating the need for providers to have “skin in the game” though MSSP and APMs and other managed care, which have already been shown to be ineffective, they offer no objective support for arriving at a 25% savings. Managed care has already been proven to be a failed experiment.

It’s too bad that they avoided the topic of single payer Medicare for All. Although that model would not reduce total spending by 25%, it would greatly improve allocation of our health care funds such that health care would be accessible and affordable for all of us forever. Milliman should at least be interested in the fact that the single payer model bends the cost curve so that we would finally bring under control the most important finding in the MMI reports, and that is the excessive health care cost escalation that we could bring down to sustainable levels through enactment and implementation of single payer financing.

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It’s clear that we need Medicare for All

By Kent Hackmann
Concord (N.H.) Monitor, Letters, May 22, 2020

Many weeks ago, a barrage of letters supported the idea that health care is a universal right, and, as I remember, no follow-up letters took an opposing view.

Yet, surprisingly, persons seem to continue to see health care as a consumer product like cell phones, TVs and leaf blowers.

The coronavirus pandemic drives home the realization that health care is both a necessity and a public good.

So what is to be done? The answer is in plain view: A single-payer Medicare for All is the best way to ensure that everyone has health coverage in good times and bad.

A single-payer system would cover everybody for all medically necessary care, regardless of employment or income. And by eliminating the waste and greed of private insurance, Medicare for All can save enough money to cover all the uninsured and upgrade coverage for the rest.

I believe that doctors here in New Hampshire would agree that they are fighting this pandemic with one hand tied behind their backs for the simple reason that health care is out of reach for countless Granite Staters. Now more than ever, we need Medicare for All.

https://www.concordmonitor.com…

COVID-19 vaccine as a ‘global public good’

Chinese vaccine would be ‘global public good,’ Xi says

By Sarah Wheaton
POLITICO, May 18, 2020

China will treat a coronavirus vaccine developed there as a “global public good,” President Xi Jinping said Monday.

China has some of the leading candidates in the global race for an immunization, with four already in human trials. While the practical implications of Xi’s commitment remain unclear, it’s a sign that Beijing is aligning itself, at least rhetorically, with a broader movement to ensure equal access to coronavirus breakthroughs.

“COVID-19 vaccine development and deployment in China, when available, will be made a global public good,” Xi told the World Health Assembly at its virtual gathering. “This will be China’s contribution to ensuring vaccine accessibility and affordability in developing countries.”

Xi’s announcement could further isolate the U.S., which has taken steps to control exports of an experimental treatment and was subject of rumors that it wanted to secure exclusive access to a vaccine.

Washington also objected to casting coronavirus remedies as “global public goods” in a resolution about the COVID-19 response expected to be adopted by World Health Organization member countries on Tuesday. Global public goods could be subject to weaker intellectual property protections or other measures to reduce their costs and make them more widely available.

https://www.politico.com…

Trump Administration Announces Framework and Leadership for ‘Operation Warp Speed’

HHS.gov, May 15, 2020

On Friday, the Trump Administration announced the appointment of Moncef Slaoui as chief advisor and General Gustave F. Perna as chief operating officer of Operation Warp Speed (OWS), the administration’s national program to accelerate the development, manufacturing, and distribution of COVID-19 vaccines, therapeutics, and diagnostics (medical countermeasures).

Dr. Slaoui is a venture capitalist and, formerly, Chairman of Global Research and Development and Chairman of Global Vaccines at GlaxoSmithKline.

https://www.hhs.gov…

Trump fires back against China’s ‘massive disinformation campaign’ about coronavirus

By Dom Calicchio
Fox News, May 21, 2020

President Trump unleashed a series of scathing tweets Wednesday night in response to what he called a “massive disinformation campaign” launched by the Chinese government regarding the coronavirus outbreak.

Trump and other critics have also accused the WHO of echoing Chinese propaganda regarding the virus instead of acting as impartial and vigilant guardians of global health.

https://www.foxnews.com…

WHO Director-General’s closing remarks at the World Health Assembly

World Health Organization, May 19, 2020

Excerpt

For everything COVID-19 has taken from us, it has also given us something:

A reminder of what really matters;

And the opportunity to forge a common future.

Dark and difficult days may lie ahead, but guided by science, together we will overcome.

Let hope be the antidote to fear.

Let solidarity be the antidote to division.

Let our shared humanity be the antidote to our shared threat.

Now, more than ever.

https://www.who.int…

Comment:

By Don McCanne, M.D.

At the virtual meeting of the World Health Organization this week, China expressed its intent to produce a much needed COVID-19 vaccine as a “global public good.” The Trump administration has launched “Operation Warp Speed” apparently in an effort to dominate the world market for the vaccine.

At a time that the world needs to be working together in controlling this terrible pandemic, today President Trump responds with belligerence towards China and the World Health Organization. He accuses WHO of not acting as impartial and vigilant guardians of global health. But that’s precisely what they are doing. President Trump has cut off funding and threatened to withdraw from WHO indicating that it is he who is not acting as an impartial and vigilant guardian of global health.

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

Drs. Adam Gaffney and Victoria Dooley on “The National”

PNHP president Dr. Adam Gaffney and Dr. Victoria Dooley appeared on the CBC program “The National” on May 15, 2020. They discussed the widespread loss of employer-based health insurance during the COVID-19 pandemic, with Dr. Gaffney noting, “My fear is that we’re going to have a second wave of suffering as a result of people going without needed health care because they can no longer afford it.”

The Coronavirus Isn’t the Only American Health Epidemic

When Andra Day’s “Rise Up” plays on the hospital loudspeakers, my spirits lift for a moment. But then I remember.

By Augie Lindmark, M.D.
The Nation, May 21, 2020

Lately my work in the hospital consists of two activities. Admit patients with Covid-19, and, if lucky, discharge patients with Covid-19. The work is monotonous. But then the loudspeakers click on and Andra Day’s “Rise Up” plays throughout the hospital, and for a moment I’m transported away from the oxygen tubes and ventilators. Someone with Covid-19 is going home. The melody offers hope, but that quickly disappears.

A couple of months ago—before all my patients had Covid-19—Peter arrived at the emergency room gasping for air. A severe asthma exacerbation had grabbed his lungs and wouldn’t let go. Peter was intubated, stabilized, and sent to the ICU. The first crisis was avoided.

The second crisis began the following day, within minutes after he was extubated. His nurse paged me: “Patient is distressed. He’s leaving ASAP.” I walked into the room and saw Peter breathing quickly, but asthma was no longer the culprit. “Do you have monthly payment plans?” he asked. His eyes held a familiar fear of uncertainty, of normalcy slipping away. Like millions of Americans, Peter was uninsured. He wanted to leave because of his mounting medical bills.

Each day I spend in the hospital now I hear that Andra Day song. With mounting Covid-19-related deaths I need some source of hope. But when I know patients are expelled back into an unreliable health care system, one that is notorious for financial ruin, celebration feels misplaced.

Far before SARS-CoV-2 dominated news cycles and hospitals alike, there were already established epidemics in US health care: namely, medical bills and uncertainty. In 2019, a third of US adults reported that their families couldn’t afford health care and 44 percent endorsed skipping a doctor’s visit because of cost. Medication affordability wasn’t much better: 29 percent of adults reported not taking a medication as prescribed due to cost.

Enter: Covid-19. You could almost hear the virus salivate.

When this coronavirus arrived in the United States, and when Donald Trump downplayed a pandemic while tests were delayed, the confusion over whether health insurance would cover testing and treatment began. The public needed confirmation that testing and treatment was accessible and affordable. Instead, Trump did what Trump does: make empty promises and baseless claims.

In a White House address on March 11, Trump incorrectly claimed the commercial health insurance industry “agreed to waive all copayments for coronavirus treatments.” He then doubled down and falsely said surprise medical bills—charges that come from out-of-network providers—would also be canceled for Covid-19. Surprise bills were not eliminated, and they still are not.

A spokesperson for America’s Health Insurance Plans (AHIP), the leading US health insurance lobby group, quickly corrected the president that the waivers were, “For testing. Not for treatment.” The beneficence of insurers, if we want to call it that, had its limits. In the president’s defense, dictating to hundreds of health insurers what they should cover outside of preventive care should be possible, but, in our current system, is a laughable proposition.

Still, testing coverage, though far from adequate, was a start. But then parsing began: What constituted coverage? Did that insurance coverage include doctor visits? Ancillary lab tests typically ordered with a Covid-19 test? Stories of Covid-19-related medical bills continued to mount, from ambulance rides to lab tests to medications. In one case reported by NBC News, a patient who recovered from Covid-19 faced over $3,000 in bills. He lamented he would have to “duke it out with my insurance company.”

Four months after the first confirmed case of Covid-19 in the US, most large health insurers now offer some form of cost-sharing waiver for Covid-19 treatment, in addition to testing. The Families First Coronavirus Response Act and the CARES Act expanded coverage for testing and treatment, but universal coverage for Covid-19 care has yet to be established.

But many large health insurers that offered fee waivers for Covid-19 treatment also set expiration dates by June 1, meaning treatment after that date wouldn’t be included, according to a recent report from Public Citizen. Furthermore, of the 25 largest health insurers, only two state that they will cover care for out-of-network providers, which opens the door to surprise medical bills.

“Insurers that are swimming in cash are trying to get credit for doing the bare minimum during an unprecedented health crisis,” said Eagan Kemp, lead author of the Public Citizen report. He further described the waivers as full of “caveats, confusing restrictions and premature end dates.”

If there’s a medical condition that would force people otherwise resistant to seeking medical care into the health system, a deadly virus is one of them. But not even Covid-19 has wiped away hesitation borne of financial fear. Last month, a Gallup poll reported that 14 percent of Americans would avoid health care due to cost if they developed symptoms of Covid-19. This number was higher among low-income individuals and people of color. Testing, contact tracing, social distancing, and treatment are all important components of pandemic responses. But the efficacy of these tools is blunted by a splintered health system that bars easy access to health care.

Perhaps the greatest risk of this pandemic is that we’ll come out on the other side with an unchanged health care system—one that causes harm. There is nothing normal about Kaiser Health News and NPR reporting a “Bill of the Month,” a recurring series on astronomical medical bills sent to unsuspecting patients. There is nothing normal about Equifax constructing a FAQ about how to negotiate your Covid-19 medical bill, which concludes by saying “Don’t forgo treatment to prevent a hospital bill; your health is too important.” There is nothing normal about staggering medical bills.

As political officials begin “reopening” public spaces and relaxing social distancing, the various forms of medical distancing placed on patients, from copays to surprise medical bills, must also be addressed—and not just for Covid-19. When uncertainty and medical bills no longer prevent health care, maybe then I’ll feel like celebrating.

Dr. Augie Lindmark is a physician and writer based in New Haven, Conn.

https://www.thenation.com…

Battle Covid-19, Not Medicare for All: Doctors Demand Hospital Industry Stop Funding Dark Money Lobby Group

"The AHA should immediately leave the PFAHCF and redirect that money to supporting patients and frontline healthcare workers."

By Jake Johnson
Common Dreams, May 21, 2020

A progressive organization of 23,000 physicians from across the U.S. demanded Thursday that the American Hospital Association (AHA) divest completely from a dark-money lobbying group that has spent millions combating Medicare for All and instead devote those financial resources to the fight against Covid-19 and to better support for patients and healthcare workers.

Dr. Adam Gaffney, president of Physicians for a National Health Program (PNHP), said in a statement that “the Covid-19 pandemic has stretched hospitals’ resources to the limit, and the AHA should not waste precious member hospitals’ funds lobbying against universal health coverage” as a member of the Partnership for America’s Health Care Future (PFAHCF).

Because Medicare for All would provide a lifeline to hospitals in underserved areas that have been hit hard by Covid-19, Gaffney argued, the AHA “cannot claim to represent hospitals while also opposing a single-payer system that would keep struggling hospitals open.” The AHA represents around 5,000 hospitals and other healthcare providers in the U.S.

As Common Dreams reported earlier this month, public health officials are accusing the Trump administration of directing billions of dollars in Covid-19 hospital bailout funds to high-revenue providers while restricting money to hospitals that serve low-income areas.

Tenet Healthcare, an investor-owned hospital company that has donated hundreds of thousands to PFAHCF, has received $345 million in Covid-19 bailout funds, Axios reported last month.

“The AHA should immediately leave the PFAHCF,” Gaffney said, “and redirect that money to supporting patients and frontline healthcare workers.”

“As physicians, we can no longer tolerate a health system that puts profits ahead of patients and public health,” Gaffney added. “It’s time for health professionals to hold accountable the organizations that claim to represent us.”

Formed in the summer of 2018 by an alliance of pharmaceutical, insurance, and hospital lobbyists with the goal of countering the push for universal healthcare, PFAHCF’s anti-Medicare for All “army” has grown rapidly since its founding, with the AHA joining the fray in 2019.

As The Intercept reported last October, the for-profit hospital industry has played an “integral role” in the corporate fight against single-payer.

“America’s hospitals and health systems strongly support improving patient access to health coverage for all Americans,” Rick Pollack, AHA’s president and CEO, wrote in a blog post last February. “That’s why we’ve joined with the American Medical Association and others as part of the Partnership for America’s Health Care Future to build on the strength of the existing reforms.”

The American Medical Association dropped out of PFAHCF last year in the face of protests from doctors and nurses, and now healthcare workers are pressuring AHA to do the same.

PNHP said it originally planned to protest outside of the AHA’s annual meeting in Washington, D.C. in April but has been forced by the coronavirus pandemic to take its pressure campaign online, “with tactics such as a petition and letter-writing campaign directed at AHA officials.”

Rev. Richard Ellerbrake, president emeritus of Deaconess Health System in St. Louis, Missouri, wrote in a letter to AHA board members that “it often seemed to me that the AHA was ahead of the American Medical Association (AMA) on many important issues of the day.”

“Today I would hope the AHA would follow the example of the AMA and discontinue supporting the PFAHCF,” wrote Ellerbrake.

https://www.commondreams.org…

COVID-19 and Medicare for All

By Ashley Duhon, M.D. and Sara Robicheaux, M.D., M.P.H.
The Lens,

Last week, we officially began our careers as physicians in the middle of a global pandemic and public health crisis. Over the previous four years as medical students, we saw countless examples of patients wronged by our health care system, which incentivizes disease treatment and not disease prevention. We saw patients lose their limbs to diabetes when they could not afford to begin insulin until it was too late. We saw patients whose access to comprehensive healthcare began with their enrollment in Medicare only after they were placed on dialysis, when we know that preventing kidney failure is more cost effective than treating it. We held the hands of our dying patients knowing that, if they could have afforded care sooner, they would be holding their loved ones’ hands instead.

Prior to COVID-19, over 40,000 New Orleanians were without health insurance. Now, with unemployment numbers rising daily, the uninsured rates will rise steadily as insurance plans tied to employment are lost. The costs of COVID-19 treatment have amounted to tens of thousands of dollars for the uninsured and could exceed $1,000 for patients with employer-based insurance. The promises of private, profit-based insurers to cover COVID-19 treatment are not enough. Many of these corporations exploit gaps in coverage to avoid having to pay for this treatment, like refusing payment for care performed by an out-of-network provider or when a patient does not receive or qualify for a COVID-19 test. As we have seen with our patients, commercial health insurance is a defective product, like an umbrella that melts in the rain. With skyrocketing premiums, copays, and deductibles, even insured patients are forced to choose between paying for rent and food or the bills for supposedly “covered” procedures. Not surprisingly, most choose food and rent. Many are avoiding treatment for symptoms concerning for COVID-19 due to concerns over the bills they will receive later in the mail.

Medical bills amounting to $1,000 or more could send many into medical bankruptcy. Medical problems have contributed to two-thirds of all bankruptcies in America, a figure that is virtually unchanged since before the passage of the Affordable Care Act (ACA). This means, even though more people have private health insurance, 530,000 families suffer bankruptcies each year that are linked to illness or medical bills. In the U.S., a whopping $450 billion of unpaid medical debts are sent to collections agencies every year. This problem disproportionally affects Louisiana and the greater New Orleans area; our state ranks second for the proportion of people living with unpaid medical bills. In Orleans Parish, the percentage of residents living with medical debt is higher than the national average. It remains to be seen how COVID-19 will continue to worsen this statistic as New Orleans has become a hot spot for cases.

We must fix our broken health care system once and for all. The only way to eliminate the nightmare of medical debt and bankruptcy is to cover everybody for all medically necessary care without the financial burden of premiums, copays, and deductibles, during and beyond a pandemic. In our view, the only way we can afford to cover everyone is through single-payer Medicare for All. Medicare for All would cut through the wasteful administrative costs and go-betweens of private insurance, and pay doctors and hospitals directly for patient care, saving our nation as much as $600 billion annually — enough to cover the uninsured and upgrade coverage for everyone else.

We don’t want to practice medicine in a system that rations healthcare based on ability to pay, or that punishes people who get sick with a lifetime of financial instability. We have seen our government take steps to cover COVID-related costs during this pandemic. However, this is not enough. The people of New Orleans deserve more comprehensive medical care that will not drain their pocketbooks. As recently graduated physicians, our first prescription is for single-payer Medicare for All.

Dr. Ashley Duhon is a recent New Orleans area medical school graduate. She will begin her residency in Obstetrics and Gynecology in the Bronx, New York in July. 

Dr. Sara Robicheaux is a recent New Orleans area medical school graduate. She will begin her residency in Emergency Medicine this July and is excited to continue to serve the people of Louisiana.

https://thelensnola.org…

Doctors’ group demands the American Hospital Association leave anti-single payer dark-money organization

The Partnership for America’s Health Care Future — partially funded by the AHA — has spent millions on lobbying and ads against universal health care

FOR IMMEDIATE RELEASE: May 21, 2020

Contact:
Dr. Adam Gaffney, PNHP President, gaffney.adam@gmail.com
Clare Fauke, PNHP communications specialist, clare@pnhp.org

Physicians for a National Health Program (PNHP), a nonprofit organization of 23,000 doctors who support Medicare for All reform, has called on the American Hospital Association (AHA) to divest its membership in the Partnership for America’s Health Care Future (PFAHCF), a dark-money lobbying group that spends millions fighting against reforms that would lead to universal health coverage. 

“The COVID-19 pandemic has stretched hospitals’ resources to the limit, and the AHA should not waste precious member hospitals’ funds lobbying against universal health coverage,” said PNHP President Dr. Adam Gaffney, who is also a pulmonary and critical care physician.

The PFAHCF is a dark-money group founded by health insurance and pharmaceutical companies, two industries whose profits are most threatened by a single-payer Medicare for All system. The PFAHCF spends millions of dollars each year running ads against Medicare for All and other reforms such as a public option. Last summer, the group bought half of all political advertising in Iowa, and spent a total of $1.2 million on anti-reform ads ahead of the Iowa caucuses. 

Several medical associations were also early members of the PFAHCF, including the AHA and the American Medical Association (AMA), the largest physician membership organization in the U.S. In August 2019, the AMA left the PFAHCF after pressure from physicians and other health advocates who protested at the AMA’s annual meeting in Chicago. Other medical professional groups, including the American College of Radiology, have recently quit their membership in the PFAHCF under pressure from health professionals. Remaining provider groups include the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the The Virginia Orthopaedic Society. 

PNHP had planned a protest outside the AHA’s annual meeting in Washington, D.C. in late April. Due to the COVID-19 pandemic, the doctors’ group has taken its campaign online, with tactics such as a petition and letter-writing campaign directed at AHA officials. 

The letter-writing campaign caught the attention of Rev. Richard Ellerbrake, who is President Emeritus of Deaconess Health System in St. Louis, Mo. When he learned that the AHA was a member of PFAHCF, Rev. Ellerbrake wrote to AHA board members that, “During my 30 years as COO/CEO of Deaconess Health System, it often seemed to me that the AHA was ahead of the American Medical Association (AMA) on many important issues of the day. Today I would hope the AHA would follow the example of the AMA and discontinue supporting the PFAHCF,” a reference to the decision by the AMA to leave the PFAHCF in August of 2019.

PNHP President Dr. Adam Gaffney said that as millions of Americans lose both their jobs and their health coverage during the COVID-19 pandemic, the need for Medicare for All is more urgent than ever before. “As physicians, we can no longer tolerate a health system that puts profits ahead of patients and public health. It’s time for health professionals to hold accountable the organizations that claim to represent us.”

Dr. Gaffney added that a Medicare for All program such as H.R. 1384, the Medicare for All Act of 2019, would provide a lifeline to struggling hospitals in rural and other underserved areas that serve an increasing number of uninsured patients. He notes that a single-payer system would fund hospitals through annual global budgets that are based on community health needs, not corporate profits. 

“The AHA cannot claim to represent hospitals while also opposing a single-payer system that would keep struggling hospitals open,” said Dr. Gaffney. “The AHA should immediately leave the PFAHCF, and redirect that money to supporting patients and frontline health care workers.”

 Physicians for a National Health Program (PNHP) is a nonprofit organization whose 23,000 members advocate for single-payer Medicare-for All. It was founded in 1987.