By Mariétou H. Ouayogodé, PhD, Alexander J. Mainor, JD, MPH, Ellen Meara, PhD, Julie P. W. Bynum, MD, MPH, and Carrie H. Colla, PhD
JAMA Network Open, July 12, 2019

Abstract

Importance

People with complex needs account for a disproportionate amount of Medicare spending, partially because of fragmented care delivered across multiple practitioners and settings. Accountable care organization (ACO) contracts give practitioners incentives to improve care coordination to the extent that coordination initiatives reduce total spending or improve quality.

Objective

To assess the association between ACO-reported care management and coordination activities and quality, utilization, spending, and health care system interactions in older adults with complex needs.

Design, Setting, and Participants

In this cross-sectional study, survey information on care management and coordination processes from 244 Medicare Shared Savings Program ACOs in the 2017-2018 National Survey of ACOs (of 351 Medicare ACO respondents; response rate, 69%) conducted from July 20, 2017, to February 15, 2018, was linked to 2016 Medicare administrative claims data. Medicare beneficiaries 66 years or older who were defined as having complex needs because of frailty or 2 or more chronic conditions associated with high costs and clinical need were included.

Exposures

Beneficiary attribution to ACO reporting comprehensive (top tertile) care management and coordination activities.

Main Outcomes and Measures

All-cause prevention quality indicator admissions, 30-day all-cause readmissions, acute care and critical access hospital admissions, evaluation and management visits in ambulatory settings, inpatient days, emergency department visits, total spending, post–acute care spending, health care contact days, and continuity of care (from Medicare claims).

Results

Among 1 402 582 Medicare beneficiaries with complex conditions, the mean (SD) age was 78 (8.0) years and 55.1% were female. Compared with beneficiaries assigned to ACOs in the bottom tertile of care management and coordination activities, those assigned to ACOs in the top tertile had identical median prevention quality indicator admissions and 30-day all-cause readmissions (0 per beneficiary across all tertiles), hospitalization and emergency department visits (1.0 per beneficiary in bottom and top tertiles), evaluation and management visits in ambulatory settings (14.0 per beneficiary [interquartile range (IQR), 8.0-21.0] in both tertiles), longer median inpatient days (11.0 [IQR, 4.0-33.0] vs 10.0 [IQR, 4.0-32.0]), higher median annual spending ($14 350 [IQR, $4876-$36 119] vs $14 229 [IQR, $4805-$36 268]), lower median health care contact days (28.0 [IQR, 17.0-44.0] vs 29.0 [IQR, 18.0-45.0]), and lower continuity-of-care index (0.12 [IQR, 0.08-0.20] vs 0.13 [IQR, 0.08-0.21]). Accounting for within-patient correlation, quality, utilization, and spending outcomes among patients with complex needs attributed to ACOs were not statistically different comparing the top vs bottom tertile of care management and coordination activities.

Conclusions and Relevance

The ACO self-reports of care management and coordination capacity were not associated with differences in spending or measured outcomes for patients with complex needs. Future efforts to care for patients with complex needs should assess whether strategies found to be effective in other settings are being used, and if so, why they fail to meet expectations.

From the Discussion

To measure whether ACO efforts to manage and coordinate care are associated with health care utilization and spending outcomes in groups likely to benefit from such services, we used data from the NSACO to form a care management and coordination index that plausibly targets older patients with complex health needs. We found wide variation in reported care management and coordination activities across MSSP participants. For example, when index scores were ranked by the level of care management activity reported, we observed large differences in the use of evidence-based approaches to care transitions for hospitalized patients. In multivariate analyses of patient-level measures for 244 ACO respondents, we found that high levels of care management and coordination intensity were not associated with significant differences in hospitalizations, inpatient days, E&M visits in ambulatory settings, spending, and health care system contact days despite large samples of beneficiaries in each group of ACOs.

Although our study is not definitive and includes several limitations, our estimates on various outcomes are indistinguishable from zero, indicating a call to invest in these areas with caution and to track local results in careful evaluations. Our results suggest that organizations should consider the effectiveness of investing heavily in care coordination activities that are difficult to implement.

https://www.ncbi.nlm.nih.gov…

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Comment:

By Don McCanne, M.D.

Regarding this study of outcomes among patients with complex needs in Medicare accountable care organizations, these authors report, “our estimates on various outcomes are indistinguishable from zero.” If there were any merit to ACOs, it should certainly show up in patients with complex needs.

As with many other studies that are reporting negligible results in their evaluations of accountable care organizations, these authors also recommend, “As ACOs focus on expanding care coordination and management efforts, it is important to continually evaluate the effectiveness of those programs for different patient populations.” More study of the same unsuccessful, mindless policy options?

There are endless conferences, seminars, and journal articles on accountable care organizations, all for naught. Yet where are the conferences on the single payer model of Medicare for All? These other conferences are a distraction from what we need to be doing – moving forward with enacting and implementing a model that would be truly effective, efficient, equitable, and affordable for all; Single Payer Medicare for All. Accountable care organizations are a dead end.

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

By Eric C. Sun, MD, PhD; Michelle M. Mello, JD, PhD; Jasmin Moshfegh, MA, MSc; Laurence C. Baker, PhD
JAMA Internal Medicine, August 12, 2019

Abstract

Importance: Although surprise medical bills are receiving considerable attention from lawmakers and the news media, to date there has been little systematic study of the incidence and financial consequences of out-of-network billing.

Objective: To examine out-of-network billing among privately insured patients with an inpatient admission or emergency department (ED) visit at in-network hospitals.

Design, Setting, and Participants: A retrospective analysis using data from the Clinformatics Data Mart database (Optum), which includes health insurance claims for individuals from all 50 US states receiving private health insurance from a large commercial insurer was conducted of all inpatient admissions (n = 5 457 981) and ED visits (n = 13 579 006) at in-network hospitals between January 1, 2010, and December 31, 2016. Data were collected and analyzed in March 2019.

Exposures: Receipt of a bill for care from at least 1 out-of-network physician or medical transport service associated with patient admission or ED visit.

Main Outcomes and Measures: The incidence of out-of-network billing and the potential amount of patients’ financial liability associated with out-of-network bills from the admission or visit.

Results: Of 5 457 981 inpatient admissions and 13 579 006 ED admissions between 2010 and 2016, the percentage of ED visits with an out-of-network bill increased from 32.3% to 42.8% (P < .001) during the study period, and the mean (SD) potential financial responsibility for these bills increased from $220 ($420) to $628 ($865) (P < .001; all dollar values in 2018 US$). Similarly, the percentage of inpatient admissions with an out-of-network bill increased from 26.3% to 42.0% (P < .001), and the mean (SD) potential financial responsibility increased from $804 ($2456) to $2040 ($4967) (P < .001).

Conclusions and Relevance: Out-of-network billing appears to have become common for privately insured patients even when they seek treatment at in-network hospitals. The mean amounts billed appear to be sufficiently large that they may create financial strain for a substantial proportion of patients.

From the Discussion

In a national sample of US patients with private health insurance, the incidence of out-of-network billing at in-network hospitals substantially increased between 2010 and 2016, from 32.3% to 42.8% of ED visits and from 26.3% to 42.0% of inpatient admissions. Moreover, the potential financial consequences of out-of-network billing in both settings nearly doubled during this period, and the top 10% of patients faced liabilities of more than $1000 for ED visits and more than $3000 for inpatient care. Sensitivity analyses suggested a lower incidence of unanticipated out-of-network billing for elective inpatient admissions, but showed a similar increase during the study period, with potential financial liabilities for patients that were similar to those in the main analysis. Overall, our findings suggest a growing risk to patients of incurring burdensome unexpected out-of-network bills.

https://jamanetwork.com…

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Comment:

By Don McCanne, M.D.

Provider networks are a tool designed by the private insurance industry to give them control over how much will be paid for health care services covered by their plans. From the patient’s perspective, a benefit of contracted networks is that the insurers can use their negotiating clout to slow the increase in premiums charged for their plans. For that the patient has the tradeoff of limiting their selection of physicians and hospitals to those on the approved provider list, or else lose the protection of fee controls negotiated by the insurers.

In an emergency situation it is inevitable that many patients will receive services from physicians who are out of network. Patients then are subject to “surprise bills” – balance billing for charges in excess of the insurers’ negotiated fees. Besides facing the possibility of receiving care from out-of-network providers in the emergency departments or when admitted for in-patient services, most emergency medical transportation is also out-of-network. This study shows that a very large percentage of patients who thought that they were well covered by their insurance plans were exposed to sometimes staggering fees for out-of-network care, creating financial hardships for many.

Imagine what would happen under a well designed single payer model of Medicare for All. There would be no segregated networks since all physicians and hospitals would be essentially “in-network.” There would be no payments for deductibles, copayments nor coinsurance. The patient would receive whatever care they needed in the emergency department or as an inpatient, and then go home after the care is rendered. There would be no surprise bills nor any other bills.

Why are there providers who are not included in the networks? In some cases it could be that they could not negotiate fees with the insurers that would be acceptable to them. But more often it is inherent in the nature of the provider network tool. Providers who agree to lower rates have the advantage of a certain amount of exclusivity – being guaranteed a larger patient population to draw from, draining patents from out-of-network providers.

In actuality, the private insurers’ payments are usually significantly higher than Medicare payments, which is then reflected in higher insurance premiums that the patient pays. So the model is not nearly as successful as they would like you to believe. Yet the Medicare model of publicly administered pricing is much more successful in containing costs.

Right now there is a debate taking place as to how patients potentially facing surprise out-of-network bills might be provided some relief. One option would be to limit surprise bills to a percentage of Medicare fees, perhaps 125 percent. But why should a physician who has not signed a contract be required to accept the conditions of the contract anyway yet without the benefit of being included on the insurers list of approved physicians? If everyone is going to have to comply with a given set of rates, then wouldn’t it be far more logical to set those rates fairly for everyone under a single payer Medicare for All program?

Another suggestion would be to establish arbitration for fee disputes, but you could imagine the additional administrative burden that this would pile on top of the existing heap of profound administrative excesses.

So not only would single payer Medicare for All be a far better fix for surprise out-of-network bills, it would fix all of the other problems with our health care financing system as well. So instead of just tweaking surprise bills, let’s go ahead and actually enact and implement a model that would be effective, efficient, equitable and affordable for everyone – single payer Medicare for All.

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

By Jake Johnson
Common Dreams, August 9, 2019

A Business Insider poll published Thursday found that most Americans with employer-sponsored health coverage support switching over to Medicare for All, undermining the right-wing narrative that the U.S. public is wedded to private insurance plans.

The survey showed that 59 percent of respondents who have employer-provided insurance “said they would support switching their employer-based health insurance to a government plan under Medicare for All” as long as quality of coverage would remain the same or improve.

The poll also found that Americans on government-run healthcare plans such as Medicare and Medicaid are more satisfied with their coverage than those on employer-sponsored plans, which have soared in cost over the past two decades.

According to Business Insider, 57 percent of respondents on government plans said they “love” their coverage. Just 41 percent of those with employer-provided plans said the same.

https://www.commondreams.org…

Business Insider:
https://www.businessinsider.com…

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Comment:

By Don McCanne, M.D.

People on Medicare are more supportive of their coverage than are people on employer-sponsored plans. Although some polls have shown that support for Medicare for All declines when respondents are told that they would lose their choice of private plans, this poll confirms that the majority would be fine with Medicare for All as long as the coverage is the same or better.

The single payer model of Medicare for All, as in the Sanders and Jayapal bills, would, in fact, provide significantly better coverage (more benefits, choice of providers, and no deductibles). If the pollsters really wanted the truth, rather than asking a followup question about losing choice of private plans, they should be asking about preference for better benefits under Medicare for All. It is disingenuous to say that people want to keep their employer-sponsored plans with fewer benefits and less stability of coverage when they could have more complete coverage under Medicare for All, guaranteed for life. But people do have to have a better understanding of the single payer model of Medicare for All. We still have more work to do.

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

By Timothy Faust

This can all feel like so much. It feels like so much to me! I sit to read or write and the waves batter me and my body feels like a towel, wet and crumpled on the floor; I fall inside myself and wish for some angelic comet to plunge into my house and gently, quietly lift us all from this national suffering. But I don’t think that’s fair of me to do. It’s not very kind to indulge in nihilism when other people have even more at stake. What do you do? How do you tilt against the grotesque squalor of the world?

My answer begins with single-payer. Single-payer won’t solve all of the problems we’ve talked about in the previous section of this book. It won’t even solve most of them: it won’t build the houses, it won’t feed the people, it won’t bring jobs or money back to rural areas. But that’s all right, in a sense— no program can, not all at once. What single-payer can do, I believe, is serve as a ladder we can climb, all together, into a better world. A properly designed single-payer program is one titanic step toward making people safe in their own homes, in their own bodies. It is a reprieve from our continual fucking-over by the structure and stricture of private insurance. And it is a method of finally demanding accountability from a state that permits (or even encourages) the sins that cause mass suffering—and the medical inequities they produce.

It’s not a hard sell. Single-payer isn’t that complicated (the real complicated shit is the various bureaucratic coping mechanisms invented to respond to the inadequacies of private insurance!) and most people like it already. More people will be drawn to it once they learn what it means and how it fits into the nooks and crannies of their lives. Most doctors and nurses like it, both because they’ve seen the devastating consequences of uninsurance among their patients and because they’d like to avoid the grating bureaucracy of trying to get paid by insurance companies.

The people who tend not to like single-payer are people who wouldn’t like anything that didn’t make them money: the insurance companies it would replace, plus the pharmaceutical, device, and hospital CEOs whose profits might be cut into by the rise of a larger, stronger, payer. Then there’s the powerful people who generally benefit from human suffering: the abusive boss who wants to make sure you can’t quit your job; the abusive husband who wants to make sure you can’t quit your relationship; the CEO who enjoys being able to cut benefits while knowing his workers can’t strike for fear of losing insurance; the lizardlike politicians who find it useful to first advance policies that let rich people plunder their districts, then blame poor people, people with disabilities, and people of color for the resulting scarcity.

These problems are not new in America. We’ve been suffering needlessly for generations. We continue this suffering because, at every conceivable opportunity, our politicians, our policy-makers, the CEOs who mine us for profit—have decided to pursue moderate, subdued, pragmatic, and useless policies. They have had every opportunity to help and have refused. They must be left behind. They’ve started coming out of the woodwork, and they’ll continue to do so for the next few years. They’ll have “responsible solutions” for “new American healthcare.” They’ll smile and go on TV and say they’re very concerned about all these problems whose structural causes they, personally, have benefited from. They will reach out to take our hands, tenderly and piously, and whisper, “This really is the best we can do right now,” as they jam them in the garbage disposal. So they’re out.

We will have to turn to each other.

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This is all to say that the work of health justice is not siloed. Housing work, healthcare work, anti-carceral work, disability liberation—all share health equity in their articulations of a better world. This and only this, I think, can bring about single-payer, and, beyond it, health justice. We have seen that movements for universal healthcare that are led from the top down have not succeeded.

Yet through this massive mobilization—and only through this massive mobilization—this is a fight we will win. Single-payer is already a wildly popular idea among the people it affects. This is not a radical proposition. We are simply discussing a basic principle of fairness.

After all, we all come from nothing. We are all fashioned from a formless and shapeless place. We have been thrust through the maw and born into a world that is arbitrary and unequal in its allocation of suffering. And yet instead of affording each other the basic dignities of being human, we have developed this bizarre system of American health in which one’s suffering is one’s own responsibility, in which empathy is vestigial and unnecessary. We have atomized suffering and, in turn, assigned blame for suffering to the people who suffer it.

I have seen such naked suffering inflicted in my American name. I have seen neighborhoods ripped apart by the unrepentant, unyielding bloodlust of capitalism. I have seen families torn limb from limb in the service of extracting profit. I have seen the dehumanizing machine all at once and felt despair. For me it is heinous to feel complicit, through my simple existence in my only and horrible home, in the mass immiseration and annihilation of those against whom the whole rotten weight of the world is stacked.

This is intolerable to me. I hope it is to you, too. And so I hope you join me in saying: enough.

Not in our name may this America persist. May we root ourselves not in fear but in love—love for those who suffer around us, as we, too, will one day suffer—and from that love, may we cultivate the fury by which this cruel machine can be destroyed.

My friends—single-payer is moral. Single-payer is necessary. Single-payer is achievable. Solidarity now, solidarity forever.

For an expanded version of these excerpts:
https://splinternews.com…

About the book, “Health Justice Now,” and how to purchase it:
https://healthjusticenow.com

Video: Tim Faust: Beyond Single Payer (45 minutes):
http://midwestsocialist.com…

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Comment:

By Don McCanne, M.D.

Timothy Faust’s new book, “Health Justice Now,” provides an excellent description of the injustices inherent in our current health care system and the reforms that we can achieve with single payer as the springboard. But he doesn’t stop at single payer. He goes on to discuss the social and structural determinants of health as part of the broader overview of health justice.

Faust is very well versed in health policy, whereas his very different communication style you might find refreshing in comparison to the typically nerdy PowerPoint discussions that many of us at PNHP have been delivering. The video (link above) includes some topics covered in his book.

So which audiences might resonate with his style and rhetoric? Young adults, particularly with a sophomoric bent, might find that his approach clarifies some of the fundamental issues of health justice. Because of his smattering of profanity and the complexity of the topic, it would not be suitable for most young children, but, even there, it may give their parents some ideas with which they could communicate health justice concepts to their children and friends and especially nonbeliever friends. It might be very useful for those confused or misled by the prevailing rhetoric supporting expansion of the Affordable Care Act or supporting the option to continue with private insurance plans, with or without a public option – rhetoric that inappropriately rejects the model that really does work: the single payer version of Medicare for All. It might also be useful for audiences who are already sold on single payer in that it may add to their catalogue of sound bites and explanations of health policy concepts – concepts that some may otherwise find to be particularly mundane. Staid, conservative libertarians may find the rhetoric and references to socialism off-putting, but that is an audience that remains quite resistant to the single payer message anyway, though, who knows, maybe this could be a spark that awakens a sense of health justice that this group seems to lack. In sum, almost all audiences could benefit from his message, in spite of or because of his unique style and rhetoric.

I would emphatically recommend watching the 45 minute video (this weekend might be a good time) so that you have a better idea of his style and message. Then buy his book, and, above all, share it with others. We need to spread the word, and this can be an effective tool.

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

By Dan Diamond
POLITICO Pulse, August 8, 2019

What GOP doctors won’t say about gun violence — They won’t use the same language as the American Medical Association and other health groups, which have insisted that the nearly 40,000 annual deaths from gun violence should be treated as a “public health crisis,” according to a PULSE review.

— PULSE checked on all 16 physicians in Congress: Did they agree with medical associations that gun violence is a public health crisis? All three Democrats — Reps. Raul Ruiz (who specialized in emergency medicine), Ami Bera (general practice) and Kim Schrier (pediatrics) — have said yes, with staff referencing previous statements, like this tweet by Ruiz, where they called for treating gun violence like other public health problems.

“Every other major cause of death in the United States has the full weight of the Federal government backing research to solve it,” Schrier tweeted in June. “The same must go for the over 35,000 gun deaths every year, including many from suicide.”

— But all 13 Republican doctors either didn’t respond to PULSE’s questions or referenced previous statements on the link with mental illness. Many of those Republicans — Reps. Ralph Abraham and Scott DesJarlais (family medicine), Michael Burgess and Phil Roe (OB/GYN), Larry Bucshon (thoracic surgery), Neal Dunn (urology), Mark Green (emergency medicine), Andy Harris (anesthesiology), John Joyce (dermatology) and Roger Marshall (urology) and Sens. John Barrasso (orthopedic surgery), Bill Cassidy (gastroenterologist) and Rand Paul (ophthalmology) — previously have expressed skepticism of Democrats’ calls for gun control.

Surgeon General Jerome Adams didn’t respond to questions about whether he agreed that gun violence is a public health crisis. “HHS is deeply concerned about violence, including gun violence, that is rooted in mental illness, an area of significant focus to the Department in terms of both research and treatment,” Adams said in a statement. “One of our missions is to help Americans with mental illness find and obtain timely treatment.”

“PULSE CHECK”: Gun violence isn’t really a mental health problem — That’s according to Amy Barnhorst, a UC Davis psychiatrist who studies firearm violence, who said that’s misunderstanding the core issue and looking for retroactive red flags.

“I understand … why it’s easy for people to believe,” Barnhorst said on POLITICO’s podcast, but “just because somebody’s weird or they behave badly … that doesn’t mean they have a mental illness” like depression or schizophrenia or would have met the criteria for a diagnosis.

“It’s a convenient distractor from the other argument, which is that all of these guys do have one thing in common,” Barnhorst added. “And that thing 100 percent contributes to their being able to be a mass shooter, and that’s a gun.”

https://www.politico.com…

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Comment:

By Don McCanne, M.D.

UC Davis psychiatrist Amy Barnhorst: “All of these guys do have one thing in common and that thing 100 percent contributes to their being able to be a mass shooter, and that’s a gun.”

It’s a public health issue. We must do better.

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

By Gretchen Jacobson, Rachel Fehr, Cynthia Cox, and Tricia Neuman
Kaiser Family Foundation, August 5, 2019

The Medicare Advantage, individual (also known as non-group), and fully-insured group (employer) health insurance markets are three distinctly different markets. Each of these private insurance markets has unique features that affect the profitability for insurers, and which in turn affect coverage for eligible people. These markets are dominated by many of the same health insurers, with most of the country’s largest health insurers offering plans in all three markets.

Average Gross Margins

Gross margins for Medicare Advantage plans averaged $1,608 per covered person per year between 2016 and 2018 – about double the average annual gross margins for plans in the individual and group markets ($779 and $855 per member per year, respectively).

Gross margins do not necessarily translate into profitability since they do not account for administrative expenses. Nonetheless, gross margins are an indicator of financial performance and signal how much insurers retain, including profits, after paying for enrollees’ covered medical expenses.

Variation in Gross Margins Over Time

In every year since 2006, average gross margins for Medicare Advantage plans have exceeded those of plans in the individual and group markets. The increase in average gross margins in the past few years has primarily been due to a sharp increase in the size and number of plans receiving bonus payments for high quality ratings, with total bonus payments more than doubling between 2015 and 2018.

Simple Loss Ratios

Simple loss ratios, or the percentage of premium income that insurers pay out in claims, provide further context about the financial status of each of these markets. Despite differences in gross margins, medical expenses comprised a similar share of total premiums collected (simple loss ratios) across plans in the Medicare Advantage, individual, and fully-insured group markets. Between 2016 and 2018, the medical expenses of Medicare Advantage enrollees averaged about 86% of the total premiums collected by Medicare Advantage plans (primarily federal payments for Medicare-covered benefits), which is similar to the individual market (84%) and fully-insured group market (84%) three-year averages.

As with the gross margins, the simple loss ratios do not account for administrative expenses, and medical loss ratios as defined by the ACA are generally higher because the ACA calculation makes adjustments for taxes, fees, and quality improvement expenses.

Reconciling Gross Margins and Simple Loss Ratios

Although loss ratios are similar across the three markets, gross margins are much higher for Medicare Advantage plans because both medical expenses and premiums are substantially higher for Medicare Advantage enrollees. In other words, a 5% margin, for example, in the Medicare Advantage market is a larger amount than a 5% margin in the individual or group market. People on Medicare tend to use more health care and incur higher medical expenses than people in the individual and group markets, and the federal payments (premiums) to Medicare Advantage plans are tied to the medical expenses of people in traditional Medicare.

Total Gross Margins

After aggregating gross margins across all plans and enrollees in this analysis, total gross margins were highest for the fully-insured group market for all years between 2006 and 2017. However, as of 2018, the Medicare Advantage market has caught up to the group market, with both markets reaching $27 billion in total gross margins in 2018. The rise in total gross margins for the Medicare Advantage market is primarily due to a steady increase in people enrolling in Medicare Advantage plans over the past decade. Total gross margins in the individual market remain significantly lower than the fully-insured group or Medicare Advantage markets, reaching $18 billion in 2018, in part because fewer people are covered in the individual market.

Discussion

This analysis suggests insurers are profitable in each of the three markets. There is a particular focus in policy debates right now on Medicare Advantage plans. Several Medicare-for-All and other health reform proposals would allow private insurers to administer benefits under a new Medicare-like public option, which could be lucrative and attractive for health insurers, depending on how payments to plans are set. Based on the history of Medicare Advantage plans, setting payments to private plans at the appropriate rate remains a challenge, given competing goals of broadening plan choice and fiscal accountability. With a new public program or option, policymakers are likely to face similar challenges, depending on their goals and priorities.

https://www.kff.org…

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Comment:

By Don McCanne, M.D.

In the Discussion in this KFF Issue Brief the authors state, “Several Medicare-for-All and other health reform proposals would allow private insurers to administer benefits under a new Medicare-like public option, which could be lucrative and attractive for health insurers.” This report confirms, in fact, that the private Medicare Advantage plans have been highly lucrative, currently with a gross margin of $1,608 per covered person per year – about twice that for plans in the individual and group markets – money that is diverted from patient care.

As you observe politicians walking away from single payer Medicare for All and endorsing a Medicare public option, it begins to make a little more sense. They are telling us that they want us to have the option of enrolling in a private plan, while the insurers are there to be sure that the private plan option is a Medicare Advantage plan.

If you don’t understand the problem here, read the August 5 Quote of the Day from Robert Kuttner, “Harris’s Fake Medicare-for-All Plan,”: https://pnhp.org…

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

By Michael Hiltzik
Los Angeles Times, August 5, 2019

The most perplexing aspect of our current debate over healthcare and health coverage is the notion that Americans love their health insurance companies.

This bizarre idea surfaced most recently in the hand-wringing over proposals to do away with private coverage advocated by some of the candidates for the Democratic nomination for president. Oddly, this position has been treated as a vote-loser.

During the first round of televised debates on July 30 and 31, only four of the 20 candidates raised their hands when asked if they would ban private insurers as part of their proposals for universal coverage: Sens. Elizabeth Warren of Massachusetts, Bernie Sanders of Vermont and Kamala Harris of California, and New York Mayor Bill de Blasio. Harris later backed away, releasing a “Medicare for all” proposal that would accommodate private insurers at least for the first 10 years.

She should have stood her ground. The truth is that private health insurers have contributed nothing of value to the American healthcare system. Instead, they have raised costs and created an entitled class of administrators and executives who are fighting for their livelihoods, using customers’ premium dollars to do so.

“Health insurers have been successful at two things: Making money and getting the American public to believe they’re essential,” says Wendell Potter. He should know, since he spent decades as a corporate communications executive in the industry, including more than 10 years at Cigna.

The insurers’ success in making themselves seem essential accounts for the notion that Americans are so pleased with their private coverage that they’ll punish any politician who dares to take it away. But the American love affair with private insurance warrants close inspection.

Let’s start by examining what the insurers say are their positive contributions to healthcare. They claim to promote “consumer choice,” simplify “the health care experience for individuals and families,” address “the burden of chronic disease” and harness “data and technology to drive quality, efficiency, and consumer satisfaction.” (These claims all come from the website of the industry’s lobbying organization, America’s Health Insurance Plans (AHIP).

They’ve achieved none of these goals. The increasingly prevalent mode of health coverage in the group and individual markets is the the narrow network, which shrinks the roster of doctors and hospitals available to enrollees without heavy surcharges. The hoops that customers and providers often must jump through to get claims paid impose costly complexity on the system, not simplicity. Programs to manage chronic diseases remain rare, and the real threat to patients with those conditions was lack of access to insurance (until the Affordable Care Act made such exclusion illegal).

Private insurers don’t do nearly as well as Medicare in holding down costs, in part because the more they pay hospitals and doctors, the more they can charge in premiums and the more money flows to their bottom lines. They haven’t shown notable skill in managing chronic diseases or bringing pro-consumer innovations to the table.

Insurers cite these goals when they try to get mergers approved by government antitrust regulators. Anthem and Cigna, for example, asserted in 2016 that their merger would produce nearly $2 billion in “annual synergies,” thanks to improved “operational” and “network efficiencies.”

The pitch has a long history. The architects of a wave of health insurance mergers in the 2000s also proclaimed a new era of efficient technology and improved customer service, but studies of prior mergers show that this nirvana seldom comes to pass. The best example may be that of Aetna’s 1996 merger with U.S. Healthcare in a deal it hoped would give it access to the booming HMO market.

According to a 2004 analysis by UC Berkeley health economist James C. Robinson, the merger became a “near-death” experience for Aetna. The deal was expected to bring about “millions in enrollment and billions in revenue to pressure physicians and hospitals” to accept lower reimbursement rates, he wrote.

“The talk was all about complementarities, synergies, and economies of scale… The reality quickly turned out to be one of incompatible product designs, operating systems, sales forces, brand images, and corporate cultures.” Aetna surged from 13.7 million customers in 1996 to 21 million in 1999, but profits collapsed from a margin of nearly 14% in 1998 to a loss in 2001.

Even when they don’t happen, insurance merger deals cost customers billions of dollars. That’s what happened when two proposed deals — Aetna/Humana and Anthem/Cigna — broke down on a single day in 2017. The result was that Aetna owed Humana $1.8 billion and Anthem owed Cigna $1.85 billion in breakup fees — money taken out of the medical treatment economy and transferred from one set of shareholders to another.

In reality, Americans don’t like their private health insurance so much as blindly tolerate it. That’s because the vast majority of Americans don’t have a complex interaction with the healthcare system in any given year, and most never will. As we’ve reported before, 1% of patients account for more than one-fifth of all medical spending and 10% account for two-thirds. Fifty percent of patients account for only 3% of all spending.

Most families face at most a series of minor ailments that can be routinely managed — childhood immunizations, a broken arm here or there, a bout of the flu. The question is what happens when someone does have a complex issue and a complex claim — they’re hit by a truck or get a cancer diagnosis, for instance?

“We gamble every year that we’re going to stay healthy and injury-free,” Potter says. When we lose the gamble, that’s when all the inadequacies of the private insurance system come to the fore. Confronted with the prospect of expensive claims, private insurers try to constrain customers’ choices — limiting recovery days spent in the hospital, limiting doctors’ latitude to try different therapies, demanding to be consulted before approving surgical interventions.

Indeed, the history of American healthcare reform is largely a chronicle of steps taken to protect the unserved groups from commercial health insurance practices.

When commercial health insurance became insinuated into the American healthcare system following World War II via employer plans, it quickly became clear who was left behind — “those who were retired, out of work, self-employed, or obliged to take a low-paying job without fringes,” sociologist Paul Starr wrote in his magisterial 1982 book, “The Social Transformation of American Medicine.”The process even left those groups worse off, Starr observed, because insurance contributed to medical inflation while insulating only those with health plans. “Government intervention was required just to address the inequities.”

Insurers wouldn’t cover the aged or retirees, so Medicare was born in 1965. Insurers refused to cover kidney disease patients needing dialysis, so Congress in 1973 carved out an exception allowing those patients to enroll in Medicare at any age. (So much for addressing the “burden of chronic disease.”)

Individual buyers were charged much more for coverage than those buying group plans through their employers — or barred from the marketplace entirely because of their medical conditions — the Affordable Care Act required insurers to accept all applicants and, as compensation, required all individuals to carry at least minimal coverage.

The health insurance industry’s most telling contribution to the debate over healthcare reform has been “to scare people about other healthcare systems,” Potter told me. As a consequence, discussions about whether or how to remove private companies from the healthcare system are chiefly political, not practical.

The Affordable Care Act allowed private insurers to continue playing a role in delivering coverage not because they were any good at it but because their wealth and size made them formidable adversaries to reform if they chose to fight it. They were sufficiently mollified to remain out of the fray, but some of the big insurers then did their best to undermine the individual insurance exchanges once they were launched in 2015.

Even as individual Americans fret over losing their private health insurance, big employers have begun to see the light. Boeing, among other big employers, is experimenting with bypassing health insurers as intermediaries with providers by contracting directly with major health systems in Southern California, Seattle and other regions where it has major plants. It would not be surprising to see the joint venture of Amazon, Berkshire Hathaway and JP Morgan Chase try a similar approach in its quest to bring down costs.

That’s an ironic development, since the private insurers first entered the market precisely by offering to play the role of intermediaries for big employers. But instead of fulfilling the promise of efficiency and cost control, they became rent-seeking profiteers themselves.

There’s no doubt that it will take years to wean the American healthcare system off the private insurance model; Kamala Harris’s proposal may be merely a recognition of the necessary time frame. It’s true that some countries with universal healthcare systems preserve roles for private insurance, including coverage for services the government chooses to leave out of its own programs or providing preferential access to specialists, at a price.

But the private insurers’ central position in America’s system is an anachronism dating back some 75 years. The sooner it’s dispensed with, the better — and healthier — America will be. The next time a debate moderator asks presidential candidates if they favor doing away with private insurance, let’s see all the hands go up.

https://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Remember that poll question that asked if you would want comprehensive health care benefits for life paid for by equitable taxes that everyone could afford, or would you rather churn through private insurance intermediaries that restrict your choices of physicians, hospitals, and medications, and that create financial and administrative barriers to keep you from getting the care you should have? Of course you don’t remember that question because it isn’t being asked. Yet we are being told that we should not support a single payer model of Medicare for All because some people want to maintain the option to have the latter.

Including private plan options under Medicare for All greatly increases the administrative waste, inequities, and costs of the system. Michael Hiltzik explains why we should just get rid of the useless private insurers instead. That view needs to be expressed loud and clear in today’s political discourse.

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