By Adam L. Logeman, MS, Oscar Ponce, MD, Neri Álvarez-Villalobos, MD, Victor M. Montori, MD, MSc
Mayo Clinic Proceedings, November 2019

The health care system in the United States is capable of both health care excellence and pricing people out of care. Key individuals can exert influence on public and private discourse, policies, and actions that are responsible for health care’s current state and envision a path forward. Since 2003, the periodical Modern Healthcare has published a yearly ranking of the 100 most influential people in US health care. The list is compiled with readership input and vetted by the periodical’s editorial board using proprietary criteria; the selection is also opaque as to what (ie, health care or clinical policy and the practice or the business of care) or who (ie, policymakers, employers, payers, clinicians, and patients) is subject to their influence. Because it receives wide reporting and limited critique, this list stands as a useful longitudinal account of who others perceive to be in a position to influence health care.

Using the published yearly list and the reported characteristics of the persons listed, we sought to determine the relative ranking over time, covering the period 2002 to 2018, of executives and administrators, academics and frontline advocates, and government officials.

There were 1700 persons named from 2002 to 2018, a minority of them women (range over the period, 17% to 28%). Most influencers are top executives from nonprofit health care provider organizations; their proportion has increased from 23% in 2002 to 72% in 2018, with an apparent substantial upward inflection in this trend since 2009. This predominance appears to be at the expense of academics, advocates, and government officials.

We found that the perceived influence over US health care of chief executives of health systems is increasing. To the extent that the ranking validly reflects influence, the sharp rise in the influence of chief executive officers at the expense of representatives of patients or health professionals may underscore the increasing industrialization of health care. It is not possible to find patients, patient advocates, clinicians, or clinician advocates at the top of this list. This trend placing health care influencers within C-suites, accountable to boards mostly comprising other corporate leaders, may explain the rise of business language and thinking—for example, high-value health care.

Our findings suggest that patients and clinicians are neither defining what health care is nor deciding how it should evolve. Urgently, they must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.

https://www.mayoclinicproceedings.org…

---

To Control Costs Expand Managed Care and Managed Competition

By Alain Enthoven, PhD; Victor R. Fuchs, PhD; Stephen M. Shortell, PhD, MPH, MBA
JAMA, November 7, 2019

The US health care financing and delivery system serves the public poorly. It costs far more than in any other country, does not produce better health outcomes, and leaves millions uninsured.

Over the years, managed care, defined as patient-centered coordinated care provided under payment incentives that reward achieving cost and quality measures, and managed competition, a market designed to create incentives for managed care organizations (MCOs) to reduce cost and improve quality and patient satisfaction, have demonstrated a potential to control costs without any sacrifice of quality.

Managed care increases efficiency of care delivery within individual health plans. Managed competition creates a structure within which health care plans compete with one another. The 2 are complementary and synergistic, and have several advantages over reforms that require government-initiated transformation of all medical care. These models offer the possibility of controlling costs without government price controls.

Managed Care

Managed care, a concept that addresses both payment and delivery, has a long history, beginning with Kaiser Permanente in the 1940s and including passage of the Health Maintenance Organization Act of 1973 and current interest in risk bearing ACOs. Managed care, fully or partially implemented, is now a widespread form of health care in most parts of the country.

2019 data suggest that more physician organizations are owned or strongly affiliated with a specific hospital/health system, reducing to some extent the overlap of physician networks.

Managed Competition

The competitors are health care financing and delivery plans based on managed care or traditional open-ended fee-for-service systems.

For managed competition to succeed, it must lead to the transformation of US health care from traditional, open-ended, uncoordinated fee-for-service systems to efficient MCOs.

From the Conclusions

When an economic or health care crisis comes, cost control will have priority, but crisis solutions are rarely the wisest. Managed care and managed competition are not panaceas. As is true of all types of medical care interventions, clinical or organizational, not every individual attempt will succeed; however, managed care and managed competition have a good record of success in controlling costs and maintaining quality without resorting to price controls, the principal alternative.

https://jamanetwork.com…

---

Comment:

By Don McCanne, M.D.

The most influential people in U.S. health care? It’s not the patients. It’s not the clinicians. It is not the academics, advocates, nor government officials. According to the Modern Healthcare survey, it’s the top executives of health care provider organizations, or leaders of “industrial health care” (forget about “medical”).

And what about the managed care revolution that failed to adequately control high health care spending and left in place the health care injustices that are so prevalent today? The deafening echo perpetuated through recent decades is intensifying in its call for yet more managed care, now often labeled as ACOs or value-based care. And what do we hear from the health care academics? Net savings performance still varies widely and quality performance is still highly variable (Health Affairs Blog, October 25, 2019). It is not working.

And just to confirm that not much has changed, the Old Guard (Enthoven et al) tell us that we need to continue to expand this model to control costs in order to avoid government price controls. What? Costs have continued their upward spiral in the private commercial insurance market (in spite of transient brief slowing) yet have been much better controlled under the government-run Medicare program. Tens of millions remain uninsured and many more remain underinsured while patients are losing their choices of physicians and hospitals. Again, managed care is not serving us well.

The private sector is not going to voluntarily bring most people under the safe umbrella of health care. When the private industry has already tapped those backed by adequate resources, only government policies can pull the rest in. Only the government can ensure that absolutely everyone is included, that financial and other barriers to access are removed, that all essential services are covered, and that the system is affordable for each of us through a universal financing system funded through equitable taxes. None of these are functions of managed care.

We need to discharge the private managed care managers and replace the system with our own public stewards. As the authors of the Mayo Clinic Proceedings article state, “patients and clinicians must find and use their collective voices to turn away from industrial health care and move decidedly toward careful and kind patient care for all.”

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

By Michael Anne Kyle, Robert J. Blendon, John M. Benson, Melinda K. Abrams, and Eric C. Schneider
Health Affairs, November 2019

Abstract

In a national survey, seriously ill Medicare beneficiaries described financial hardships resulting from their illness—despite high beneficiary satisfaction with Medicare overall and the fact that many have supplemental insurance. About half reported a serious problem paying medical bills, with prescription drugs proving most onerous.

Conclusion

Medicare insurance is broadly popular, but seriously ill beneficiaries who most need financial protection report widespread problems affording care and financial instability.

https://www.healthaffairs.org…

---

Comment:

By Don McCanne, M.D.

Medicare should be especially advantageous for beneficiaries with serious illness, but about half reported a serious problem paying medical bills.

Although “Medicare for All” initially referred to the vastly superior single payer model of reform, the label has been corrupted. For some it refers to merely adding a Medicare-like public option to our dysfunctional system of health care financing. For others it means that your insurance through work will be taken away from you, and, to compound problems, your taxes will go up.

Regardless of labels, it is imperative that the public understands that the single payer model would provide affordable, comprehensive health care for absolutely everyone. No other model, whether or not labeled “Medicare for All,” comes close. That begins by understanding that we are not proposing to continue with the inadequate traditional Medicare program, but we would be replacing it with a vastly improved version, whether labeled “Single Payer Improved Medicare for All” or whatever.

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

By John Furse
London Review of Books, November 7, 2019

The Americanisation of the NHS is not something waiting for us in a post-Brexit future. It is already in full swing. Since 2017 Integrated Care Systems (ICSs) have been taking over the purchasing as well as the provision of NHS services in England, deciding who gets which services, which are free and which – as with the dentist and prescriptions – we have to pay for. Known in the US as Accountable Care Organisations (ACOs), ICSs are partnerships between hospitals, clinicians and private sector providers designed – and incentivised – to limit and reduce public healthcare costs, and in particular to lessen the demand on hospitals. Health Maintenance Organisations (HMOs), the forerunners of ACOs, were pioneered by the US health insurance provider Kaiser Permanente in 1953. President Nixon’s adviser John Ehrlichman explained to his boss the basic concept before the passage of the 1973 HMO Act: ‘The less care they give them the more money they make.’ In May 2016 Jeremy Hunt, then health minister, admitted at a Commons Health Committee hearing that Kaiser was a model for his planned NHS reforms. When a trial of ACOs was announced in the UK in 2017, it caused an outcry from campaigners and NHS England quickly rebranded them ICSs. But the Kaiser model isn’t new to healthcare policy in the UK: it has been the inspiration for the long and discreet process of the dismantling and reformation of the NHS since the 1980s.

In his report to the Conservative Party’s Economic Reconstruction Group in 1977, Nicholas Ridley wrote that “denationalisation should not be attempted by frontal attack but by preparation for return to the private sector by stealth. We should first pass legislation to destroy the public sector monopolies. We might also need to take power to sell assets. Secondly, we should fragment the industries as far as possible and set up the units as separate profit centres.”

After coming to power two years later, Thatcher was able openly to denationalise many industries, but the NHS, with its huge number of staff and institutions, its largely effective and equitable provision of healthcare and its great popularity, was a far more difficult proposition. In 1986 hospital cleaning services were privatised. In 1988 Oliver Letwin and John Redwood published Britain’s Biggest Enterprise: Ideas for Radical Reform of the NHS, which proposed turning the NHS into an independent trust and advocated joint ventures with the private sector and the introduction of fees.

The first major legislative step was the creation of the internal market. Kenneth Clarke’s 1990 NHS and Community Care Act split the NHS into ‘service purchasers’ and ‘service providers’: hospitals and GPs would compete for custom and the successful parties would be rewarded with greater funding. The influence of the HMO model and of the Kaiser consultant Alain Enthoven was acknowledged in Parliament by the then Tory MP Quentin Davies. ‘The fund-holding practice concept owes something to the system of HMOs in the United States … Elements of the Bill reflect some of the thinking of Professor Enthoven in his famous report and reflect his concept of an internal market.’ Enthoven was seen as an expert on ‘unsustainable growth’ in health expenditure and in 1985 his report ‘Reflections on the Management of the National Health Service’ had advised the Thatcher administration that ‘in competition doctors impose on themselves controls they would never dream of accepting if the government tried to impose them.’ ‘The system needed to be reconfigured,’ he later explained, ‘in such a way as to give incentives to motivate the self-interest.’

Letwin and Redwood’s ideas also had traction in Tony Blair’s 1997 National Health Service Act. Together, the 1990 and 1997 Acts turned NHS hospitals into trusts able to operate as commercial businesses. Many formed Private Finance Initiative partnerships to build and maintain hospitals – these deals, originally worth £11.4 billion, have lumbered the NHS with more than £80 billion of debt. Under New Labour a number of hospital trusts commissioned Kaiser and United Health, the largest US private health insurer, to run pilot programmes. ‘Consumer choice’ had been the mantra of the Thatcher era; under New Labour NHS patients became consumers and the goal ‘patient choice’.

These changes were minor compared to those introduced by the 2012 Health and Social Care Act (Letwin was by then a senior figure in Tory policy-making), which enabled hospital trusts to raise 49 per cent of their budgets from private patients and other sources, and to use NHS ‘brand loyalty’ to attract patients to their private services. In 2017 Swindon’s Great Western NHS Hospital advertised its private service saying: ‘Our patients benefit from a premium environment while having immediate access to specialist services often only available in large NHS hospitals.’

The Act gave more than 60 per cent of the NHS budget to local Clinical Commissioning Groups (CCGs), comprised of GPs and other clinicians, to be used to commission services from the private sector as well as from the NHS. Writing anonymously, one GP described the change as ‘how to get turkeys not only voting for Christmas but also plucking, basting and putting themselves in the oven’. Given their lack of business expertise, CCGs were provided with Commissioning Support Units run by private companies including KPMG, Price Waterhouse Cooper, McKinsey and Optum, the UK subsidiary of United Health. In practice, these companies now run the franchising of NHS services.

A key part of the 2012 Act, to which McKinsey was a significant contributor, was the abolition of the health minister’s responsibility for national healthcare provision. This was left to NHS England under its new director, Simon Stevens, a former health policy adviser to the Blair government appointed by David Cameron because ‘he knows more about NHS problems and market solutions than any man alive.’ In his previous role as a CEO of United Health, Stevens had led corporate opposition to the introduction of Obamacare. His ‘Five-Year Forward View’, launched in 2015, became the basis for NHS England’s Sustainability and Transformation Plans (STPs), drawn up with Optum and McKinsey. The STPs were supposed to create savings of almost £5 billion a year by 2020. As in the Kaiser model, costs are cut by reducing access to care. (Meanwhile, the revolving door continued to turn: senior government and NHS England figures who took prominent positions at Optum include Cameron’s health adviser Nick Seddon, NHS England’s commissioner David Sharp and its mental health director Martin McShane.)

The STPs divided England into 44 CCG-run ‘footprint’ areas, all of which were put under pressure to amalgamate hospitals and shrink specialist units. Hospital beds have been progressively cut: the UK’s bed-to-patient ratio is now one of the lowest in any developed country. Accident and emergency departments, which not only require expensive equipment and high numbers of staff but also take the brunt of social care failings, are in the process of being cut from 144 to about fifty. GP care is increasingly provided by ‘physician associates’, nurse practitioners and pharmacists, while patients are exhorted to use privately owned, profit-making online and app consultancies such as Doctaly, GP at Hand and myGP. Opening up new markets for US tech giants is a key factor in the reconfiguration of the NHS.

Enforced centralisation has resulted in ‘hub’ hospitals and fewer, larger GP practices: at least a thousand have closed since 2014 and the number with more than twenty thousand patients has tripled. With funding incentives from NHS England, GPs are merging their practices into competing, largescale organisations with names like Primary Care Networks and Super-Practices, or becoming partners in commercially driven Multi-Speciality Community Provider centres. These reduced and restructured services are open to takeovers by private companies. NHS hospitals now lease space on their own premises to private companies. Guy’s Hospital, in the absence of the funding it needed to develop adequate cancer facilities, rented space to the Hospital Corporation of America for private cancer suites that were given access to the hospital’s facilities. The merging of public and private provision in the same space usefully blurs the distinction between them. And the rationing of non-urgent operations such as hip replacements and restrictions on follow-up therapies – as well as increased waiting times – encourage patients to seek private treatment.

A recent report by the Strategy Unit, an NHS consultancy, acknowledges that ICSs are designed to ‘moderate’ demand and reduce spending, while their partners keep the savings they make if they run below budget. It cautions that, as with ACOs, there is ‘only limited assurance that providers will not game the system and that quality will not suffer … large financial rewards may flow out of the NHS.’ At the 2012 World Economic Forum, Stevens (then working for United Health) led proposals to replace public healthcare systems around the world with accountable care systems. His collaborators included Medtronic, the world’s largest producer of medical devices (a US company based in Ireland for tax purposes), Qualcomm Life, which designs medical technology, and Kaiser. Since his arrival at NHS England, the influence of such companies has grown: IBM is now a lead supplier of IT; Optum runs GP referrals services and is in a partnership with the second largest GP federation, Modality. The UK’s largest GP network, the Practice Group, is owned by the American company Centene. Similar companies, such as the Priory Group, are major players in mental healthcare provision and are involved in mental health ICSs.

Private companies, with their increased overheads, higher rates of borrowing and shareholder dividends, are inherently more costly to the public than state-funded services. Less obvious are the high costs of management and administration involved in franchising and marketing services. In the US these are estimated to account for more than 30 per cent of the $3.6 trillion spent on healthcare. A 2010 report commissioned by the Department of Health estimated management and administration costs at 14 per cent of total NHS spending, more than twice the figure in 1990. Commercial confidentiality laws and opaque NHS accounting make the costs of privatisation hard to quantify but privatisation is probably adding at least £9 billion a year to the NHS budget.

Stevens was recently praised by politicians and the media when he called for the repeal of Section 75 of the 2012 Health and Social Care Act, which requires competitive market tendering for the provision of services – ostensibly a move away from privatisation. But the real reason lies in the small print. Section 75 subjects private contractors to the Competition and Markets Authority. Its repeal will deregulate the sector and make ICSs more attractive to companies. Andrew Taylor, the founding director of the Co-operation and Competition Panel for NHS Funded Services, told a Commons committee hearing in May: ‘I don’t think anyone’s realistically talking about removing the private sector from the NHS. What the proposals do in effect is deregulate NHS markets. They don’t actually remove markets from the NHS.’

The Ridley Report’s proposals for denationalisation are being hurried to fulfilment. NHS property and land assets worth £10 billion are being sold to private developers. The fragmentation of a once fully integrated service into competing and commercially-driven units is well advanced and has been accomplished without proper public scrutiny, knowledge, consent or appropriate Parliamentary legislation. Successive governments have been assisted by the failure of the media to recognise the overall shape of the project and sufficiently analyse the disparate changes. ICSs will be fully up and running throughout England within 18 months.

https://www.lrb.co.uk…

---

Comment:

By Don McCanne, M.D.

This one you simply have to read. Only by doing so will you be able to understand why the change taking place in England’s NHS explains “how to get turkeys not only voting for Christmas but also plucking, basting and putting themselves in the oven.”

One snippet to pique your interest: When the UK introduced ACOs (US-style Accountable Care Organizations) the outcry caused NHS England to quickly rebrand them as ICSs (Integrated Care Systems). ICSs will be fully up and running throughout England within 18 months.

It’s turkey season. Big time!

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

By Moody’s Analytics
BlueCross BlueShield, November 6, 2019

In the course of the last several years, millennials have shown that they are very different from previous generations in a number of ways. Defined as the generation born from 1981 to 1996, they are the largest, most educated, and most connected generation the world has ever seen. However, recent data also show the beginnings of troubling generational health patterns that could hamper the future prosperity of millennials, and in turn the prosperity of the U.S. If the current pace of decline in millennial health continues unabated, the long-term consequences to the U.S. economy could be severe.

Millennials now make up the largest share of the U.S. population and labor force, placing them at the heart of U.S. economic growth as consumers, workers, and business owners. How their health plays out in the years ahead will determine not only the overall health of the country, but also its potential economic trajectory. By using Blue Cross Blue Shield Health Index data to analyze these questions, we are able to take a much broader and forward-looking view of these impacts relative to previous studies. In our examination of millennial health patterns we have found several interesting and concerning findings, particularly regarding future impacts on healthcare costs and economic activity.

1. Millennials are seeing their health decline faster than the previous generation as they age. This extends to both physical health conditions, such as hypertension and high cholesterol, and behavioral health conditions, such as major depression and hyperactivity. Without intervention, millennials could feasibly see mortality rates climb up by more than 40% compared to Gen-Xers at the same age.

2. These accelerated declines will result in greater demand for treatment and higher healthcare costs in the years ahead. Under the most adverse scenario, millennial treatment costs are projected to be as much as 33% higher than Gen-Xers experienced at a comparable age.

3. Poorer health among millennials will keep them from contributing as much to the economy as they otherwise would, manifesting itself through higher unemployment and slower income growth. Under the most adverse set of projections, lower levels of health alone could cost millennials more than $4,500 per year in real per-capita income compared to similarly aged Gen-Xers. Such impacts would be most likely concentrated in areas already struggling economically, potentially exacerbating instances of income inequality and contributing to a vicious cycle of even greater prevalence of behavioral and physical health conditions.

Counting the Costs

The logical first consequence of a less healthy population is an increase in the amount of treatment that will need to be accessed. This, of course, is not without cost. Therefore, the first step in examining the consequences of millennial health patterns over time is to try to quantify the increased healthcare costs associated with faster declines in overall health. To do this we rely on our 10 year projections of millennial health across ages, genders, and conditions. The cost of care can vary greatly based on all three of these criteria.

Given the projected increase in prevalence among the top 10 conditions examined as part of this study, we expect a sizable increase in the number of millennial patients seeking treatment over the next decade under both the baseline and adverse scenarios.

Because a majority of millennials are still in their late 20s and early 30s it is unlikely that we will experience the full brunt of these costs within the next decade. The youngest millennials won’t turn 40, around the time when most of these conditions historically begin to reach critical mass, for another 17 years. This means that the projected increases in millennial costs of care over the next decade may be just the tip of the iceberg, with more serious implications beyond the current forecast horizon.

As millennials continue to age beyond the next decade, higher prevalence rates for physical conditions such as hypertension and high cholesterol mean these costs will rise even higher compared with previous generations over the long run.

The increase in the cost of treatment for millennials will contribute to the already growing impact of healthcare costs on the U.S. economy. The Centers for Medicare and Medicaid Services estimates that national health expenditures already make up more than 17% of the U.S. economy, growing to nearly 20% within a decade. This carries significant implications for the nature of U.S. economic growth, particularly with regard to consumer and government spending.

Expanding out-of-pocket costs for consumers will limit their ability to spend on other goods and create additional stress within already strapped household budgets.

Less Healthy, Less Wealthy

The second important consequence of a less healthy working-age population is slower economic growth. An economy is traditionally measured by how much it is able to produce, via its gross domestic product. At its core, GDP is made up of two primary components, the number of individuals producing, and the amount that each individual is able to produce. Both of these components are threatened by lower levels of health in the workforce.

As part of our previous research with the BCBS Health Index we established that workers who are less healthy also tend to be much less productive, generating lower per-capita incomes and being employed less often. As millennials become less healthy, they are more likely to miss work or stop working altogether. Furthermore, even when they are working, health concerns may prevent them from being as productive as they would have been had they had the same health profile as previous generations.

In addition to making up a larger portion of the overall population, millennials are now the largest contributors to the U.S. labor force.

If a majority of American workers are generating less income than they otherwise would, we can reasonably assume that overall productivity and thus GDP will also grow at a slower rate than if millennials had exhibited similar health outcomes to previous generations.

In addition to a potentially slower rate of headline economic growth, millennial health patterns have the potential to exacerbate some underlying economic issues as well. Income inequality, for example, has grown in recent decades for a variety of reasons. Having previously established the fact that there is a strong correlation between overall health and several important economic measures, we can conjecture that some of the areas that may see the largest economic drag from lower millennial health are areas with already below average economic outcomes.

These findings should serve as a call to action among policymakers and the healthcare community at large to address declining health among younger Americans before the more severe consequences in this analysis become reality. If nothing is done, the impacts could be game-changing for the U.S. and its economy.

https://www.bcbs.com…

---

Comment:

By Don McCanne, M.D.

Our nation is facing two interrelated problems that demand immediate attention. Income and wealth inequality have had a deleterious impact on the personal finances of a majority of Americans, resulting in insecurities of essentials such as housing, food, and health care. Our health care financing system has compounded the problems by diverting health care dollars to worthless endeavors such as our profound administrative excesses and to paying very high prices that shift ever more health care funds to the wealthy. This has resulted in personal financial hardship and further impairment of access to our health care delivery system.

Today’s report should alarm the millennials. They are now the largest contributors to the U.S. labor force, and their role in driving the economy and its impact on the people will only grow larger. Yet they are already experiencing greater financial hardship and significantly poorer health than the generation preceding them. Health care and income inequality are already at a pre-crisis level requiring immediate attention.

The plutocrats may have the resources to implement much needed solutions to these problems, but, unfortunately, they have shown us that their only interest is to maintain control of government policy which continues to move more wealth to the top, further draining the masses of funds that are essential to meet the socioeconomic needs of the individuals in our society.

When the private sector is failing it becomes imperative that the stewards of our public policies move in to correct the deficiencies, of course with the consent of the people. In this case, we desperately need public policies that would establish a health care financing system that includes everyone, reduces waste, removes financial barriers to care, and is funded equitably, through taxes, so that health care is affordable for everyone. That is precisely what a single payer Medicare for All program would do. But we also need public policies that would address the extreme inequalities in income and wealth – not eliminate inequality, but rather make it equitable. There is an overlap of these two arenas that cry out for public policy solutions – health care and income inequality. The policy solutions are complementary – move to a single payer financing system that is effective and equitable, and pay for the system through equitable, progressive tax policies.

The millennials need to wake up. Their day is just around the corner and they are now stepping into that pit that is portending disaster.

And, oh, besides health care financing and equitable distribution of income, they have another issue that requires public policies – the disaster of climate change. If they don’t do something quick then it is unlikely that there will be a need for health care financing and for equitable distribution of income on a planet in which Homo sapiens is an extinct species.

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

By Lexi Churchill
ProPublica, October 31, 2019

In early August, Elizabeth Petersen was home-schooling her children in the kitchen of their northern Idaho home when she got a call from Providence Sacred Heart Medical Center, where her 4-year-old son, Paul, was set to have surgery a few weeks later.

Since having a stroke around his first birthday, Paul had been under treatment to restore use of the right side of his body. He had recently graduated from a feeding tube and needed surgery to close a hole in his stomach.

The hospital’s surgery department reached out to alert the family that Paul was no longer covered by Medicaid. Petersen broke down in tears, knowing she could not afford the surgery without the government health insurance.

“I was shocked to hear it,” Petersen said.

Petersen’s anxiety grew after she called the state Medicaid agency to find out why Paul was abruptly cut from coverage before her son was due for his reevaluation. The agency employee insisted Petersen had failed to meet an annual deadline for reporting detailed financial information — which Petersen contends she knew nothing about.

Families like the Petersens are wrestling with administrative burdens that are one reason more than 1 million children across the country are no longer covered by Medicaid and the Children’s Health Insurance Program, two government-run programs for low-income children. It is the first enrollment decline in a decade.

States across the country have implemented updated paperwork requirements, but Idaho is the first to attribute its new administrative burdens to direct instructions from the Centers for Medicare and Medicaid Services under the Trump administration.

CMS has promoted safeguards to help catch improper payments to ineligible recipients. In Idaho, this meant a major change to procedures that it established in the Obama years. Idaho led the nation in allowing Medicaid recipients to renew coverage automatically, without requiring additional documentation, but CMS has deemed some of the state’s procedures inadequate.

Idaho’s changed requirements have ensnared in red tape many recipients who have no income or are self-employed.

The Affordable Care Act, the Obama administration’s landmark health care policy overhaul, required states to modernize eligibility procedures, and state Medicaid agencies began developing IT systems that could automatically verify recipients’ income. New technology allowed states to avoid asking recipients for new annual paperwork by comparing their reported incomes with state and federal income data.

If the eligibility system found contradictions, the state could then ask for more information. When the data confirmed that recipients’ income fell below the cut off, the systems could automatically renew their coverage without paperwork hassles. This is also called an “ex parte” renewal.

Jennifer Wagner, a senior policy analyst at the Center on Budget and Policy Priorities in Washington, said the shift to verifying income electronically removes many bureaucratic hoops that can penalize qualified recipients unfairly if “they didn’t receive a document, they didn’t send in the right information or the state is overwhelmed and failed to process that renewal timely.”

Many parents learned from their child’s medical provider that they had been dropped from coverage. Others received a final notice informing them they’d been dropped, though they said they never received the initial paperwork.

Many who did receive notices were confused, since the new forms did not clearly explain the changed requirements.

Many state and federal administrators chalked up the trend to an improved economy, which may have helped boost residents’ income so they no longer qualified for Medicaid or led them to jobs with private insurance.

However, the latest census insurance data released in September made clear that a healthier economy was not a blanket reason for declines. As the number of recipients enrolled in Medicaid and CHIP dipped, the number of uninsured residents rose. Meanwhile, those with private insurance coverage remained virtually the same.

Advocates have pointed to a number of Trump administration policies that have driven former recipients away from Medicaid and CHIP. One of the most commonly discussed proposals is the “public charge” rule, which would count immigrants’ reliance on public programs against them if they apply for a green card.

State-driven processes have also contributed. Minnesota’s Medicaid agency recently sent recipients a new form asking for permission to verify their assets, giving them a few weeks to respond before coverage was suspended. The majority of the 70,000 recipients who lost coverage in Missouri in 2018 were removed after failing to return the mailed renewal form.

The Affordable Care Act instructs states to officially renew recipients once a year unless there is a change in circumstances. Under the Trump administration, CMS has encouraged Medicaid agencies to look for those changes more frequently.

For the remaining recipients affected by the change, often the state’s poorest residents who report having no income and the self-employed, CMS does not yet see any reasonable way to confirm their eligibility without requiring additional paperwork.

https://www.propublica.org…

---

Comment:

By Don McCanne, M.D.

The Trump administration has frequently stated that they want to reduce the administrative hassles in our health care financing system. Yet they are increasing administrative complexity for Medicaid beneficiaries which seems to have contributed to the fact that more than a million children are no longer covered by Medicaid and the Children’s Health Insurance Program.

The health care financing system should be designed to help people get the health care that they need. Now we have a system that erects administrative and financial barriers to that care.

If the Trump administration really did care they should adopt a system that greatly reduces administrative complexity and provides automatic equitable financing that would ensure that everyone would have the care they need, such as a single payer Medicare for All program. Instead they use rhetoric such as “Medicare for All means Medicare for none.”

A million children. We should blame ourselves since we have failed to elect government stewards with a heart and a soul. If we can get that right, the rest should follow.

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

By Aaron Carroll, M.D.
JAMA Forum, October 30, 2019

As “Medicare for all” gains steam in the Democratic primary, many physicians are concerned about reduced revenues from the program compared with private insurance. Even an expansion of the program, as many candidates’ plans call for “Medicare for more,” causes angst. Inevitably, some physicians will threaten to opt out of Medicare and refuse to see patients.

Such calls are, for the most part, bluffs. We need only examine how many physicians have followed through on past threats to see that.

For years, the Association of American Physicians and Surgeons claims that it’s simpler for physicians to opt out of Medicare than to stay in. Physicians have not been listening.

It’s important to understand that even when physicians threaten to opt out periodically, very few ever do. In 2010, for the first time ever, the number of physicians who had officially opted out of the program with the Centers for Medicare & Medicaid Services (CMS) reached triple digits—a total of 130. That’s out of the 850 000 or so licensed physicians in the United States that year.

The Medicare Access and CHIP Reauthorization Act of 2015, or MACRA, made it easier for physicians to get out if they wanted to. Before that, physicians needed to re-file with the program every 2 years. After 2015, however, opt-outs could be permanent, lasting until physicians filed affidavits to opt in again. With that, opt-outs climbed to their historically highest level in 2016. Even then, though, there were only 7400.

That number represents fewer than 1% of physicians. And, as a Kaiser Family Foundation infographic in JAMA pointed out, more than 40% of them were psychiatrists.

Today, CMS updates its data on physicians who opt out of Medicare quarterly, and the list of clinicians who have filed affidavits is easily accessed online. As of October 2019, psychiatrists, 3911 of them, remain—by far—the largest group of physicians who choose not to participate in Medicare. They’re followed by clinical psychologists, dentists, oral surgeons, and clinical social workers.

Recently, a study in the Journal of General Internal Medicine delved deeper into the population of psychiatrists who opt out of Medicare. The authors found significant variation in where psychiatrists who opted out practiced. In more than a third of hospital referral regions, none did. California and New York had the highest opt-out rates, but even there, the averages across the state were only 10% and 13% respectively.

Older psychiatrists (those 65 years or older) were most likely to opt out, as were those who identified as female. Those who graduated from a top-20 ranked institution were more likely to leave, and those who graduated from a foreign medical school were much less likely to do so. Perhaps most significantly, psychiatrists were more likely to opt out when there was little competition in their geographic area.

Still, there’s a general sense that we have a shortage of mental health services, including for elderly patients, and it’s not optimal that so many physicians who might see them have chosen not to do so for Medicare beneficiaries. But more concerning are physicians who might serve in a primary care capacity.

There, the numbers who refuse are smaller. Family medicine has only 1544 physicians who opt out. Internal Medicine has only 1003.

Of course, even if physicians choose not to fully opt out of Medicare, they may elect not to accept new patients. A Kaiser Family Foundation analysis (excluding pediatricians) found that only 72% of primary care doctors were willing to accept new patients with Medicare in 2015. Of course, only 80% were willing to accept new patients with private insurance.

Given the overwhelming number of physicians who accept Medicare, it’s ironic that so many people think that they’ll have an easier time finding a physician if they have private insurance coverage. One of the most common ways that private insurance reduces its cost is by establishing networks, and then steering their beneficiaries to physicians in them. Usually, the cheaper the plan, the smaller the network.

Medicare Advantage, the privatized optional form of Medicare, has fewer options than traditional Medicare. Another Kaiser Family Foundation analysis showed that networks of Medicare Advantage plans included, on average, fewer than half of physicians in any county. Too few patients realize this. Even when they do, research shows that they have trouble figuring out which doctors they can really see.

There are plenty of reasons to be concerned about a transition to a Medicare-for-all type of system in the United States. Any big transition, even if it wound up being better than what we had before, would likely cause major disruption. But a mass exodus of doctors from Medicare is unlikely. Physicians need to see patients, and in such a system, all the patients would be covered by one carrier.

Even in a “Medicare for more” system, evidence from the past shows us that the vast majority of physicians are likely to remain. The ones who won’t may be more vocal, but they’ll be the exception, not the norm.

https://newsatjama.jama.com…

---

Comment:

By Don McCanne, M.D.

Some opponents of single payer Medicare for All claim that there would be a mass exodus of physicians if a universal, single payer version of Medicare were enacted and implemented as the sole payment source for health care in America. Aaron Carroll explains why this is highly unlikely.

These predictions fail to understand the nature of the physician. From the earliest days that students decide that they want to become physicians, they know that they are planning to enter a profession (not a “business”) that is dedicated to caring for patients. It is not as if they would try to give this a go and if they didn’t like it they could move on to some other business venture. This isn’t to say that there aren’t those who may identify lucrative opportunities within health care and align themselves in that direction. But even there, the primary concern of the physician (not the medical-industrial complex) would remain the delivery of health care for the benefit of the patient.

It is often claimed that under Medicare for All prices would be reduced to Medicare rates (some proposals even specify this) and that they are too low to sustain physician interest in continuing to work in the profession. First of all, the classic single payer model calls for negotiation of fees or capitation rates. The public stewards would balance their role in preventing overpayment that might excessively enhance the wealth of the physicians, with providing enough monetary resources to ensure adequate capacity in the system while at the same time providing fair margins for the physicians.

But let’s assume that the payment level is at the current Medicare prices. Would that really be too low to sustain physicians’ practices? There would be increased revenues since physicians would no longer have nonpaying charity cases – the system would cover those patients – and there would no longer be unpaid accounts or patient bankruptcies due to uninsured patients being unable to pay their bills. Also there would no longer be losses due to the inability to collect deductibles, coinsurance and copayments since they would go away. More importantly, the profound administrative burden placed on physicians would be lifted under a single payer system, and, assuming the same payment rates, those exorbitant administrative costs would be recovered. For most practices that would be more than enough to fill in the difference between Medicare payment rates and commercial insurance payment rates. Also the experiences in other nations have shown that there is not a net reduction in compensation with expansion of their systems to cover almost everyone.

The predicted physician exodus under Medicare for All is not just a bluff, it is a total myth.

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

By Elizabeth Warren
Medium, November 1, 2019

There are two absolute non-negotiables when it comes to health care:

One: No American should ever, ever die or go bankrupt because of health care costs. No more GoFundMe campaigns to pay for care. No more rationing insulin. No more choosing between medicine and groceries.

Two: Every American should be able to see the doctors they need and get their recommended treatments, without having to figure out who is in-network. No for-profit insurance company should be able to stop anyone from seeing the expert or getting the treatment they need.

Health care is a human right, and we need a system that reflects our values. That system is Medicare for All.

The best way to fight misinformation is with facts. That’s why today, I’m filling in the details and releasing a plan that describes how I would implement the long-term policy prescriptions of the Medicare for All Act and how to pay for it.

Under my plan, Medicare for All will cover the full list of benefits outlined in the Medicare for All Act, including long-term care, audio, vision, and dental benefits. My plan will cover every single person in the U.S., and includes common-sense payment reforms that make Medicare for All possible without spending any more money overall than we spend now.

Option 1: Maintain our current system, which will cost the country $52 trillion over ten years. And under that current system –

• 24 million people won’t have coverage, and millions can’t get long-term care.
• 63 million have coverage gaps or substandard coverage that could break down if they actually get sick. And millions who have health insurance will end up going broke at least in part from medical costs anyway.
• Together, the American people will pay $11 trillion of that bill themselves in the form of premiums, deductibles, copays, out-of-network, and other expensive medical equipment and care they pay for out-of-pocket — all while America’s wealthiest individuals and biggest companies pay far less in taxes than in other major countries.

Option 2: Switch to my approach to Medicare for All, which would cost the country just under $52 trillion over ten years. Under this new system –

• Every person in America — all 331 million people — will have full health coverage, and coverage for long-term care.
• Everybody gets the doctors and the treatments they need, when they need them. No more restrictive provider networks, no more insurance companies denying coverage for prescribed treatments, and no more going broke over medical bills.
• The $11 trillion in household insurance and out-of-pocket expenses projected under our current system goes right back into the pockets of America’s working people. And we make up the difference with targeted spending cuts, new taxes on giant corporations and the richest 1% of Americans, and by cracking down on tax evasion and fraud. Not one penny in middle-class tax increases.

That’s it. That’s the choice. A broken system that leaves millions behind while costs keep going up and insurance companies keep sucking billions of dollars in profits out of the system — or, for about the same amount of money, a new system that drives down overall health costs and, on average, relieves the typical middle class families of $12,400 in insurance premiums and other related health care costs.

No middle class tax increases. $11 trillion in household expenses back in the pockets of American families. That’s substantially larger than the largest tax cut in American history.

---

America’s middle class is facing a crisis. For a generation, wages have remained largely flat while family costs have exploded. I’ve spent decades sounding the alarm about it. I’m running for President to fix it. That means doing whatever we can to reduce the overall strain on family budgets.

Medicare for All can be a huge part of the solution. When fully implemented, my approach to Medicare for All would mark one of the greatest federal expansions of middle class wealth in our history. And if Medicare for All can be financed without any new taxes on the middle class, and instead by asking giant corporations, the wealthy, and the well-connected to pay their fair share, that’s exactly what we should do.

https://medium.com…

---

Comment:

By Don McCanne, M.D.

Elizabeth Warren’s proposal for Medicare for All is helpful because it shows us that we can provide affordable, comprehensive care for everyone without increasing taxes on the middle class. That is possible because of the efficiency features of the single payer model and because income and wealth inequality have provided a revenue source accessible though equitable tax policies.

Like Bernie Sanders, she is advancing a bona fide single payer model of Medicare for All. That is in sharp contrast with those models that perpetuate the current system, including the ACA exchanges, with the addition of a public option such as a Medicare buy-in. An even sharper contrast is found in the models that would begin to disassemble what programs we do have, shifting more of the costs to the patient even if clearly unaffordable. The status quo/public option models leave major deficiencies in place, whereas the models that merely unravel our system leave the majority worse off.

Providing a 44 page explanation of her Medicare for All proposal certainly gives Elizabeth Warren’s opponents plenty of nits to pick. You can almost hear the sound bites already. What is important is that essentially everyone will be better off except that the wealthy are already receiving all the care they need or want. It is true that they might suffer some angst when they look at what would likely be not much more than a footnote on their personal financial statements, but that seems to be a small price to pay for health care justice for all.

PNHP has a mission to educate colleagues and the public at large on single payer health reform, but the organization does not endorse any candidates for political office.

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