PNHP

High-deductible health plans cause women to delay breast cancer care

High-deductible health plans cause women to delay breast cancer care

Vulnerable And Less Vulnerable Women In High-Deductible Health Plans Experienced Delayed Breast Cancer Care

By J. Frank Wharam, Fang Zhang, Jamie Wallace, Christine Lu, Craig Earle, Stephen B. Soumerai, Larissa Nekhlyudov, and Dennis Ross-Degnan
Health Affairs, March 2019

Abstract

The effects of high-deductible health plans (HDHPs) on breast cancer diagnosis and treatment among vulnerable populations are unknown. We examined time to first breast cancer diagnostic testing, diagnosis, and chemotherapy among a group of women whose employers switched their insurance coverage from health plans with low deductibles ($500 or less) to plans with high deductibles ($1,000 or more) between 2004 and 2014. Primary subgroups of interest comprised 54,403 low-income and 76,776 high-income women continuously enrolled in low-deductible plans for a year and then up to four years in HDHPs. Matched controls had contemporaneous low-deductible enrollment. Low-income women in HDHPs experienced relative delays of 1.6 months to first breast imaging, 2.7 months to first biopsy, 6.6 months to incident early-stage breast cancer diagnosis, and 8.7 months to first chemotherapy. High-income HDHP members had shorter delays that did not differ significantly from those of their low-income counterparts. HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas also experienced delayed breast cancer care. Policies may be needed to reduce out-of-pocket spending obligations for breast cancer care.

From the Discussion

This study found that both vulnerable and less vulnerable women experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation following an employer-mandated switch to high-deductible health plans. Although magnitudes of delays among women in the three income categories were not statistically different at a 95 percent level of certainty, the graduated duration of the delays in the expected direction suggests true differences. For example, HDHP enrollment was associated with delays in chemotherapy initiation of 8.7 months among low-income women, 8.1 months among middle-income women, and 5.7 months among high-income women. We also detected delayed breast cancer care among HDHP members living in metropolitan, nonmetropolitan, predominantly white, and predominantly nonwhite areas.

These results suggest that HDHP-associated delays in breast cancer care are only partially related to patients’ sociodemographic characteristics and that women across the income spectrum might experience high out-of-pocket spending obligations as a barrier to breast cancer care. The delay of approximately five to seven months in early-stage breast cancer diagnosis among women across the sociodemographic spectrum could imply suboptimal breast cancer outcomes.

High-income women have greater ability to afford out-of-pocket expenses than low-income women do, so our finding that high-income women experienced substantial delays in breast cancer care was unexpected.

Our findings raise concerns that in coming years a majority of commercially insured women of all sociodemographic levels could experience delayed breast cancer care.

Conclusion

Both vulnerable and less vulnerable women who were switched to high-deductible health plans experienced delays in breast cancer diagnostic testing, early-stage diagnosis, and chemotherapy initiation, compared to women remaining in low-deductible health plans. Such delays could lead to adverse long-term breast cancer outcomes affecting a substantial proportion of commercially insured women who develop breast cancer. Policy makers, health insurers, and employers should consider implementing value-based features in HDHPs to encourage successful transitions through key stages of the cancer care pathway. This could take the form of increased HSA contributions or “population-tailored” exclusions of essential care so that women would pay minimal amounts for services such as breast diagnostic testing.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

We have serious problems with our health care financing system – a system that costs twice the average per capita of other wealthy nations yet falls miserably short in performance. In the meantime, the policy community busies itself with fixes that have clearly failed to bring our expensive system up to the standards of other nations. One of those fixes is high-deductible health plans.

Deductibles have fallen short as a policy tool, yet the policy community still insists that they have to be of benefit since they would make patients better health care shoppers by exposing them to more of the costs of their care. Their policy diagnosis is that, for deductibles to work, patients are going to have to feel more financial pain. Thus they have been increasing the deductibles to reach that threshold where pain occurs.

The policy community is quite smug now because moving to higher deductibles is working, according to their terms. People are limiting or delaying care because of these deductibles, thus meeting the goal of reducing health care spending. Or, in our terms, is it really working? Is it smart health care shopping if the financial exposure causes patients to delay diagnosis and treatment of breast cancer? Should women be waiting to be sure that they really need this care by seeing if they develop further invasive or metastatic disease? Just asking that question depresses and even nauseates me. Yet this study confirms through a “natural experiment” that women are delaying breast cancer care when they are shifted to plans with high deductibles.

As an individual obsessed with the study of health policy as it applies to our health care system, I am disappointed to see that the authors suggest implementing “value-based” features – perhaps increasing contributions to health savings accounts – as a means to reduce the stress of out-of-pocket spending for breast cancer. Not only is this a feeble response, it ignores the fact that these consumer-driven policies negatively impact the care of all serious medical problems, not just breast cancer.

We need a fundamental restructuring of our health care financing system. Right now with all of the talk about single payer Medicare for All it is almost impossible to avoid knowing what form that restructuring should take. A well-designed, single payer Medicare for All program, free at the point of service, would make essential health care accessible and affordable for absolutely everyone. And yet too many of today’s politicians and many in the policy community seem to think that an extreme measure would be to allow individuals to buy a Medicare plan as they exist today that would cover on the average only about half of health care costs, but don’t dare take away our private insurance (that relies on high deductibles and other perversities). Or rather, many say, we should just limit ourselves to building on the highly deficient Affordable Care Act.

Excuse me, but I have to barf.

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Medicare for All, a plan to improve access and health disparities

Additional care would extend American lives

By Jessica Schorr Saxe, M.D.
The Charlotte Post, March 8, 2019

Would you like to improve health statistics for African Americans, as well as other residents of the United States?

Americans lag behind other wealthy countries in health, with lower life expectancy and more deaths in infants and in mothers around the time of childbirth. In Charlotte, infant mortality is about five times as high for African Americans as for whites, a statistic that should shock us all.

Almost half of Americans either are uninsured or underinsured, which means that, although they have health insurance, they are at risk for not getting health care due to cost or getting needed care and not being able to afford their bills. And these numbers are worse for minorities.

Fortunately, there is a solution in sight. Rep. Pramila Jayapal filed HR 1384, the Medicare for All Act of 2019 in the House of Representatives on February 27. The true Medicare for All bill, it would improve on current Medicare by adding additional coverage such as vision and dental care; and eliminating the deductibles and co-pays (which result in almost one out of four seniors having cost-related problems getting medical care) and would extend it to everyone.

By eliminating private insurance companies, it would also be simpler for patients and providers because it would eliminate the unending maze of differing eligibility, forms, formularies, prior authorizations, and networks of different insurance plans (which then have to be revisited when a patient changes insurance). The bureaucratic relief translates into savings. Currently 30 percent of health care spending in the US, about $1 trillion, is due to administrative costs, and half of that is wasted. That $500 billion savings could be used to actually deliver health care.

The concept of Medicare for All has now become so popular that we are besieged by imitations, such as the Medicare for All Choice Act and the Choose Medicare Act. Sometimes referred to as the Medicare for More bills, these purport to be more politically palatable because they would be gradual routes to insure more people. However, they have serious shortcomings.

Most are a variation of a public option, which allow some people to choose to buy into Medicare. Choice sounds attractive, but making it an option means it won’t be universal. We will still have uninsured people who won’t get adequate routine care. And, though they may feel invincible, they will still be at risk for motorcycle accidents or leukemia requiring a bone marrow transplant. And we will all end up paying for their care, in the most inefficient way.

Secondly, rather than cutting down on bureaucracy, a public option will create its own new bureaucracy with yet a new set of eligibility criteria, forms, etc.

Lacking the simplicity of true Medicare for All, it will maintain the headaches and expense of the current system.

Can our nation afford to implement Medicare for All? The question should be, “Can we afford not to?” Researchers at the Political Economy Research Institute found that it would reduce health care spending in the U.S. by 10 percent—while also covering every person in the nation.

Concerned about those employed by the insurance industry? The Medicare for All Act of 2019 contains funding for job retraining and transition. Those with jobs in the new system will actually have jobs that contribute to delivering health care, not denying it.

Some politicians are concerned that the public will object because they are attached to their employer-based insurance plans or because they fear increased taxes. Surely the public values their choice of doctors and hospitals, which would improve when all are in a single plan rather than fragmented networks, and would not mourn losing high deductibles and surprise medical bills. Surely they would rather see family health spending decrease by thousands of dollars even if taxes went up a little. And surely the public values health. If everyone had access to health care, we could probably live longer and have fewer babies and mothers dying, especially in the African American community.

We should remember we are that public. Call your member of Congress and tell them you want a comprehensive, universal system that saves money for individuals and the economy—and that they should support HR 1384, The Medicare of All Act of 2019, the real deal.

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

http://www.thecharlottepost.com…

Buffett, Bezos, Dimon & Gawande’s “Haven” not living up to the hype

Haven, accessed March 7, 2019

Haven was established by Amazon, Berkshire Hathaway, and JPMorgan Chase to bring together the resources and capabilities of the three companies to create better outcomes, greater satisfaction, and lower costs for their U.S. employees and families.

Frequently Asked Questions

Why was the name ‘Haven’ chosen?

It reflects our goal to be a partner to individuals and families and help them get the care they need, while also working with clinicians and others to make the overall system better for all.

How is Haven going to improve health care?

We are pursuing a number of common-sense fixes, as well as innovative approaches, to address issues like making primary care easier to access, insurance benefits simpler to understand and easier to use, and prescription drugs more affordable. We are also looking at new ways to use data and technology to make the overall health care system better.

Is Haven going to replace existing doctors or insurance companies?

We are interested in working with clinicians and insurance companies to improve the overall health care system. We will be an ally of anyone who is working to make health care better for patients.

Who is Haven going to help?

Our focus is the U.S.-based employees and families from Amazon, Berkshire Hathaway, and JPMorgan Chase. In time, we intend to share our innovations and solutions to help others.

https://havenhealthcare.com

Comment:

By Don McCanne, M.D.

When Warren Buffett (Berkshire Hathaway), Jeff Bezos (Amazon) and Jamie Dimon (JPMorgan Chase) announced that they would join together to address the problems with our health care system, there was considerable hype that, along with their CEO Atul Gawande, these titans of the private sector would finally bring us the solutions that we needed for our overpriced and underperforming health care system.

Now that their health care venture is getting underway it is no surprise that their efforts initially will be confined to meeting the health care needs of their own employees with no involvement for the rest of the nation, except perhaps to serve an example.

Given the limits of our current dysfunctional health care system, at first glance their approach seems reasonable: improve access to primary care, improve employee understanding of the health insurance benefits, attack the high prices of pharmaceuticals, and investigate ways that data and technology might be used to improve the health care system. Although aren’t we already doing these things, albeit not equitably and not very effectively? And doesn’t this fall terribly short of the comprehensive reforms that we desperately need?

One of their proposals that stands out is the dependence on employer-sponsored private health insurance – the clarion call of the opponents of single payer Medicare for All. That implicitly supports profound administrative waste, fragmentation of health care financing, perpetuation of limited health care choices through the restrictions of provider networks, and the perpetuation of deductibles and other cost sharing that create financial barriers to care and potentially expose patients to financial hardship and even personal bankruptcy.

It would be much more beneficial for theses titans to abandon support of the current dysfunctional health care financing system, and instead advocate for a system that would solve their and everyone else’s health care problems – a single payer Medicare for All program. They would not have to do it alone, but it sure would help if they decided to participate in the orchestration of a movement culminating in a truly beneficial national health program for all of us. What an opportunity they seem to be missing. It’s shameful.

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Single payer improved Medicare for all

By Colleen C. Lyons, M.D.
Nevada Appeal (Carson City, Nev.), March 6, 2019

What?! U.S. taxpayers pay more ($6,500 per capita) than any other nation to provide healthcare to just two-thirds of our citizens (elderly, disabled, public employees, veterans, etc). And yet, unlike the other 15 highly developed nations, who provide care for all their citizens, we don’t get the national, universal, quality healthcare they get. In fact as of 2018 data, we spend another $4,200 for every man, woman and child in this country for a total of $10,700 for each and every one of us. For all this money, we get the worst care, as well. Study after study finds the U.S. ranking last among developed nations on overall health system quality, while some of the developing nations frequently rank better than America on numerous quality measures.

What is going on?! Three major things: 1) other nations have a single system of care verses our half-dozen plus; 2) other nations have healthcare systems that are NON-profit; 3) all other nations have far more primary care physicians than the U.S. does. They understand the importance of primary care and have a physician workforce compromised of 50-70 percent primary care physicians (family doctors, pediatricians and internists) versus the 30 percent we have in the U.S.

In America we keep chipping away at the problem of getting medical care. First, the Veterans Administration was created for our veterans who suffered military-service related injuries or illnesses, then Medicare for the elderly and Medicaid for the extreme poor and disabled in the mid-1960s. These were followed by CHIPS for children falling through cracks and FQHC clinics for urban and rural underserved areas. Most recently, “ObamaCare” (Affordable Care — ACA) has required insurance companies cover pre-exiting conditions, eliminate lifetime limits and cover our kids through age 26. The ACA, also, allowed states to expand Medicaid coverage for their citizens, which Nevada did, and provided the working poor and self-insured with possible subsidized insurance coverage, in the hopes of making insurance affordable. Of course, we do need to keep in mind health insurance isn’t actual healthcare, as so many people have experienced and can attest to.

Physicians for a National Health Program (PNHP.org) has proposed America adopt a “Single Payer Improved Medicare for All” program similar to what Canada adopted in the mid-1960s. A system of publicly funded, but privately provided care. Canada currently provides healthcare for all of its citizens at a cost of $4,800 per capita. PNHP’s plan eliminates the 15-20 percent cut our FOR-profit health insurance industry takes off the top from our premiums. Further, by essentially eliminating the health insurance industry, Canadian hospitals and doctors spend half what U.S. facilities and providers do to get paid with administrative expenses of 12 percent versus America’s 25 percent of revenues. Additionally, a single payer system has the leverage to negotiate significant discounts in the price of medications and medical devices, for an estimated savings of $116 billion a year. A mere savings compared with the $476 billion saved by eliminating the insurance middleman and the For-profit motive, while creating a single system of care. Enough savings to care for the one in three Americans who have no insurance or lack adequate insurance. Enough savings to improve our current Medicare, in which 20 percent of seniors forego care due to the associated costs. PNHP’s plan eliminates co-pays, deductibles, and the need for co-insurance, while covering the addition of dental care and long-term care, which aren’t currently provided by Medicare.

The Institute of Medicine estimates medical errors are the third leading cause of death in the U.S., due in large part to a lack of a coordinated single system of care. “Single Payer Improved Medicare for All” as proposed by PNHP.org would create a single national system of care. Thus, when you travel out-of-state, you won’t be out-of-network.

Dr. Colleen C. Lyons is a family physician and member of Physicians for a National Health Program.

https://www.nevadaappeal.com…

High-need patients disenroll from private Medicare Advantage plans

Analysis of Drivers of Disenrollment and Plan Switching Among Medicare Advantage Beneficiaries

By David J. Meyers, MPH; Emmanuelle Belanger, PhD; Nina Joyce, PhD; John McHugh, PhD; Momotazur Rahman, PhD; Vincent Mor, PhD
JAMA Internal Medicine, February 25, 2019

From the Introduction

More than one-third of Medicare beneficiaries are now enrolled in MA (Medicare Advantage), an increase from 19% in 2007. Medicare Advantage differs from TM (Traditional Medicare) in that private insurance plans are paid by the Centers for Medicare & Medicaid Services (CMS) on a capitated basis to cover the care of their enrollees. Because payments are fixed, this model incentivizes payers to reduce spending. Medicare Advantage plans may emphasize better primary care and care management services for high-need enrollees to prevent expensive acute services down the line. Two potential barriers to these benefits exist: capitated payments when not properly risk adjusted may incentivize “cream skimming” and “lemon dropping” (ie, attracting healthier individuals and dropping those with higher needs). Medicare Advantage plans may also restrict physician networks and require prior authorization for care. These policies may be challenging for high-need enrollees, potentially leading to poorer experiences. Understanding the experiences of high-need beneficiaries enrolled in MA is vital if the benefits of managed care are to work for this group.

A growing body of literature suggests that concerns remain regarding MA plans for high-need enrollees. Although some disenrollment may be driven by error in plan choice, MA switch to TM occurs at higher rates after significant health events and kidney failure. Evidence from the nursing home industry suggests that MA enrollees have access to lower-quality nursing homes and have high rates of disenrollment after admission. The Government Accountability Office has expressed concern that sicker patients disenroll in a biased manner. This possibility is of particular concern for patients with complex chronic conditions or multiple morbidities who stand to lose the most in disruptions to continuity of care. Disenrollment is often a sign of revealed preference, perhaps even more so if disenrollment rates are differential by patient type, which might suggest that the program does not address the preferences of these enrollees with high use of medical services.

From the Results

Across all groups, high-need enrollees had the highest rate of MA disenrollment by the end of 2015, with 2.6% (95% CI, 2.4%-2.7%) non– dual-eligible enrollees leaving the highest-rated plans and 10.6% (95% CI, 10.0%-11.2%) non–dual-eligible enrollees leaving the lowest rated plans. Disenrollment rates tended to be higher among those enrolled in lower-quality plans. Full dual-eligible enrollees left MA at the highest rates, with 11.1% (95% CI, 10.6%-11.6%) leaving the highest-rated plans and 18.5% (95% CI, 17.8%-19.3%) leaving the lowest-rated plans. However, dual-eligible beneficiaries also left TM to enter MA at the high rates, with more than 15% of non–high-need, fully dual-eligible TM enrollees switching to MA during the study period.

23.0% (95% CI, 22.3%-23.9%) of non–dual-eligible, high-need enrollees in low-rated MA plans disenrolled to TM, and disenrollment was even higher at 42.8% (95% CI, 40.5%-45.1%) among comparable high-need dual-eligible enrollees. Generally, enrollees in lower-rated plans disenrolled at higher rates than enrollees in higher-rated plans. Even in 5.0-star plans, however, high-need enrollees were more likely to disenroll (4.9% [95% CI, 4.6%-5.2%] of non–dual-eligible high-need enrollees compared with 1.8% [95% CI, 1.8%-1.9%] of non–dual-eligible and 2.4% [95% CI, 2.1%-2.7%] of dual-eligible non–high-need enrollees).

From the Discussion

We find that high-need and dual-eligible enrollees have substantially higher disenrollment rates when compared with non–high-need enrollees. This finding aligns with that of the recent Government Accountability Office report on disenrollment and other recent examples from the literature that suggest that MA plans may not currently meet the preferences of high-need enrollees. We also found large movement of TM enrollees into MA during the study period, particularly among dual-eligible beneficiaries, indicating a high level of switching in this population.

Several factors may explain differential disenrollment during this study period. Although risk adjustment has mitigated some cream skimming, plans may still not have an incentive to retain their high-need enrollees, leading to adverse selection not on who enrolls in plans but on those who disenroll. The limitations (eg, narrow networks, prior authorizations, etc) enacted by MA plans to control costs may not align with the preferences of enrollees who have complex care needs. Lower disenrollment rates from high-rated plans may be indicative of these plans providing fewer restrictions in access to care or other benefits to such enrollees. Beneficiaries with better health and socioeconomic status may also be better equipped to make more informed plan choices when first enrolling in MA. High-need enrollees may select suboptimal contracts when they first enroll in the program, and, when faced with the limitations those contracts contain, may be prompted to switch more often than healthier enrollees. High-need enrollees may also be enrolled in lower-rated plans because their more serious health needs exert a downward pull on the overall contract rating.

The largest changes in enrollment status from TM to MA and from MA to TM occurred among enrollees with dual eligibility with Medicaid. This finding is likely explained in part by dual-eligible enrollees being able to switch plans at any point during the year. An interplay between a state Medicaid managed care program and an MA plan may encourage more switching.

Conclusions

We find that high-need enrollees, particularly those who are dual eligible, disenroll from MA at substantially higher rates than other enrollees. Thus, our findings suggest that caution is warranted when evaluating the performance of MA plans owing to the potential for selection bias stemming from differential disenrollment. As of now, disenrollment is only 1 of 35 to 45 measures included in the MA star ratings system. Weighting disenrollment more heavily may help incentivize plans to address these concerns further. Although MA may have the potential to provide greater care coordination to address complex patient needs, it is unclear whether high-need enrollees who stand to benefit the most from care coordination are in fact benefiting.

https://jamanetwork.com…

Comment:

By Don McCanne, M.D.

The private Medicare Advantage insurers have been successful in marketing their plans, presumably because the enrollees perceive the plans to be superior to the traditional Medicare program, perhaps partly because of the touted benefits of managed care. However, this study shows that high-need enrollees, particularly those who are dual eligible (enrolled in both Medicare and Medicaid) disenroll from Medicare Advantage plans at substantially higher rates than other enrollees.

Supporters of privatization of Medicare through Medicare Advantage plans claim that patients are very satisfied with their coverage, but this report suggests that may be true only for individuals who do not have high health care needs. If they do have greater needs, they disenroll at higher rates.

Back in the days of the managed care revolution and the earlier Medicare + Choice plans, it quickly became evident that the healthy go into the plans and the sick come out. It appears that the tools of the current private Medicare Advantage plans have not reversed this trend. The plans seem to succeed primarily by keeping the low-cost healthy patients happy (lower cost sharing and extra benefits funded by the taxpayers), but shouldn’t we expect more out of our health care system?

Why don’t we improve Medicare and then expand it to cover everyone while using equitable public financing to make it affordable for each of us? Then everyone would be happy with the system, regardless of their medical needs.

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

Many Families Are Not Prepared For the Financial Burden of Medical Crises

Two-thirds of Americans who file for bankruptcy do so after they’re hit medical crises. And the problem isn’t getting better.

By Aaron Stern
Fatherly, March 6, 2019

Few things in your physical mailbox inspire more fear than the windowpane envelope return addressed to a doctor’s office or insurance provider. The bottom line in those bills often leads to discomfort, but for many Americans it can lead to crisis: According to a new study, more than half a million families declare bankruptcy each year due to medical expenses, and the proportion of Americans filing for bankruptcy due to unaffordable medical care has not declined since the passage of the Affordable Care Act (ACA).

High deductibles and copays, as well as inadequate disability coverage, are a major reason why 66.5 percent of all bankruptcies are filed due to medical problems, says Dr. David Himmelstein, a professor of urban public health at Hunter College, and a co-author of the study that was published by the Consumer Bankruptcy Project (CBP) in the American Journal of Public Health last month.

“I think American families are in deep trouble,” Himmelstein says. “There are enormous numbers of families that are in very precarious financial condition, and basically just one illness away from financial ruin.”

The families feeling this pain most intensely are middle class, not poor families, Himmelstein says, because families with limited income typically don’t have the credit required to run up debts high enough to claim bankruptcy, nor the resources to obtain the requisite legal assistance.

“For middle-class people, the vast majority have insurance,” Himmelstein says. “But increasingly they have insurance that has so many deductibles, copayments, uncovered services, surprise bills — all those things, that it doesn’t really protect them. And often the bills arrive at the same time that income is going down, because they’re out of work because of illness. So, there’s sort of a double whammy of combined medical bills and loss of income.”

Obamacare was supposed to ease the financial pain of health insurance, but Himmelstein’s group surveyed a random sample of 910 Americans who filed for bankruptcy between 2013 and 2016 for their report and found that the results were virtually unchanged from when they studied the same issue from 2001 to 2007, prior to the implementation of the ACA.

“It may have done something, but the underlying issues were getting worse at the same time. So, health costs were continuing to go up since our earlier study, so, basically, Obamacare may have just been bailing a leaking ship,” he says. That’s due in part to the fact that among the signature accomplishments of Obamacare was expanding Medicaid coverage — something that benefits poor people, not middle-class families, and so would not lead to fewer bankruptcies. Plus, many of the plans offered under the ACA had high deductibles and copays, Himmelstein says.

“A lot of the plans that were sold on the exchanges came with $5,000 deductibles, and for a large swath of Americans, a $5,000 medical bill that comes before you have insurance, that’s tantamount to bankruptcy, particularly if you’re losing income [due to being out of work] at the same time,” he adds.

So, if any of this is relatable to you, what can you do to protect yourself? Himmelstein does not have good news for you.

“I don’t think there’s much you can do, other than to try and have savings. That’s nice to say, but if people don’t have enough income to put away savings, that’s sort of nice advice, but no one can follow it,” he says. “I don’t think there’s really an individual solution to this. I think we need to have society-wide solutions.”

A single-payer system, a la the Medicare-for-all solutions touted by many of the Democratic presidential candidates, would be the best start to a solution, Himmelstein says.

“I don’t think there’s any other option that could work for the medical bills part of it,” he says. “In addition to single-payer, we also need better disability coverage.

Given the current political climate and the fierce opposition to government-funded health care, Himmelstein isn’t optimistic this problem will get better any time soon, meaning last month’s report may not be the last of its kind from Himmelstein and his CBP co-authors.

“Well, we have been doing it for years, and I hope we don’t have to do it in the future,” he says. “But we may well have to.”

https://www.fatherly.com…

Let’s take health care off the bargaining table

By Larry Brown
The Stand, March 5, 2019

Union members enjoy some of the best health care that working-class Americans can expect to receive. Unions have fought long and hard to establish and maintain these benefits and they are justly proud of their achievements. In the absence of a national health plan, they have sacrificed much to negotiate a modicum of security for their members and their families.

More than half of all Americans still access health care through employment-based benefit plans. There is a myth that Americans love their health plans and want to preserve them at all costs. But providing an important public good like health care as a benefit linked to employment rather than as a right available to all is an accident of history. This linkage is not only a bad idea, it is also simply unsustainable.

No other advanced industrialized country links health care to employment like the U.S. does.

Workers in other countries don’t have to fear losing their health care when they lose their jobs, nor are they chained to a job that they hate because they need the health care coverage. They don’t have to worry about their children aging out of their health plans or of losing their benefits as a result of a long-term illness that disrupts their employment. They are not subject to the constant churning of health plans and provider networks and the confusing and ever-changing array of deductibles, co-payments, out-of-network charges that even the best of plans impose on their members.

And importantly, these employer-based health care plans put American companies at a competitive disadvantage against rival businesses in other countries that have national or single-payer health care systems.

The Milliman Medical Index reports that total health care costs for a family of four with decent employer-provided coverage exceed $28,000 per year. This comes to $14 per hour worked by a full-time employee. The average employer pays nearly $16,000 towards those costs and the worker picks up the remaining $12,000 through a combination of payroll deductions, co-pays and deductibles. The total costs have consistently increased 2, 3 and 4 times faster than the rate of inflation. And the percentage paid by the worker has gone up nearly every year since 1994.

That is why health care has become the biggest cause of strikes, lockouts and concession bargaining. Health care costs drive wage stagnation as unions routinely trade off wage increases and other benefits in order to maintain basic health care for their members and retirees. Unscrupulous non-union employers gain an unfair competitive advantage over worker-friendly businesses by shortchanging their own employees’ health care benefits.

Unions do not serve their members well by trying to circle the wagons around an unsustainable model of employment-based health care. That is why the AFL-CIO, the Washington State Labor Council, and dozens of unions have called for a social insurance model like Medicare for All.

The time has come to take health care off the bargaining table by making it a right for all Americans.

Larry Brown is President of the Washington State Labor Council, AFL-CIO. The WSLC is the state’s largest union organization, representing the interests of some 600 locals and councils with approximately 550,000 rank-and-file members working in Washington state.

http://www.thestand.org…

Dr. Adam Gaffney on ‘Washington Journal’

PNHP president Dr. Adam Gaffney appeared on “Washington Journal” on C-SPAN on March 5, 2019. He debated Joseph Antos of the American Enterprise Institute, answered questions from callers, and made the case for a single-payer national health program (i.e. improved Medicare for all) as an affordable, equitable solution to our ongoing health care crisis.

Conflating patient primacy with the patient-as-a-consumer metaphor

Patient-Centered Care, Yes; Patients As Consumers, No

By Michael K. Gusmano, Karen J. Maschke, and Mildred Z. Solomon
Health Affairs, March 2019

Abstract

There are numerous calls for building health care delivery systems that are more patient centered. The focus on patient-centered care has increasingly begun to rely upon, and even merge with, the concept of patients as consumers. Early references to patients as consumers were made by patient advocates who were attempting to challenge professional and corporate dominance in health care. Today, “consumer-driven” health care has become associated with neoliberal efforts to emphasize market factors in health reform and deemphasize government regulation and financing. In our view, a narrow focus on consumerism is conceptually confused and potentially harmful. The consumer metaphor wrongly assumes that health care is a market in the usual understanding of that term, that the high cost of US health care is a function of excessive consumer demand, and that price transparency and competition can deliver on the promise of reducing costs or ensuring quality. Furthermore, a consumer metaphor places disproportionate burdens on patients to reduce health care costs, and it could erode professional obligations to provide appropriate and effective care.

Introduction

Building a health care delivery system that is more patient centered has a lengthy history, including powerful grassroots efforts beginning in the 1960s. These initiatives see patient-centered care as an important means of improving health outcomes and a morally worthy good in itself. As a means to an end, patient-centered care includes efforts to make the care delivery system more efficient and easier for patients to navigate. Patient engagement—a particular form of patient-centered care—yields better, well-documented outcomes by stimulating patients to take on more active roles in promoting and maintaining their health. As a moral end in itself, patient-centered care emphasizes the importance of honoring patients’ values and preferences, and it is less paternalistic and more respectful. Although there are concerns about how the concept might be misapplied, there is broad support for it, evidenced by federal investment in studying how best to ensure patient-centered outcomes and patient-centered outcomes research.

Increasingly, however, the focus on patient-centered care has begun to rely upon, and even merge with, the concept of patients as consumers. In this article we call for greater vigilance in distinguishing patient-centered care from the concept of consumer-driven health care. Too often consumer-driven health care is used as if it were a synonym for patient-centered care. We argue that consumer-driven care is based on critical myths about what creates, and what can rein in, high-cost care. Moreover, the consumer-driven concept can easily place the burden for systemwide cost containment on the shoulders of individual patients. In this article we offer a brief history of the patient-centered care movement, demonstrate how the language of patient-centeredness is becoming appropriated by those advocating market reforms, and then articulate why the consumer metaphor is misguided and potentially harmful.

Origins of the Patient-Centered Care Movement

In contrast to the early use of these terms to connote ways of empowering patients, consumer driven and consumerism are now associated with market-oriented health reforms that place a burden on patients to solve cost and quality problems. These consumer terms function as metaphors that represent conceptual confusion and are potentially harmful. The terms wrongly assume that health care is a competitive market and that the high cost of US health care is a function of excessive consumer demand. Because these requisite assumptions are not met, the metaphor’s remedy—price transparency and competition—cannot deliver on the promise of reducing costs or ensuring quality. Moreover, it is misleading to use consumer driven, defined in this narrow sense, as a synonym for patient centered. A consumer metaphor could also erode obligations by policy makers and health care systems to build a truly patient-centered care system.

Health Care Is Not a Market

Patients can be construed as consumers only if they are operating within a market. But health care is not a market in the usual way that markets are defined, and thus patients do not have the power that consumers have to shape that market. Patients are not as well informed as physicians are about medical care. Often patients do not have well-formed preferences, and they seek care under circumstances in which they do not have the time or emotional stamina to shop around on the basis of quality and price. And if policy makers treat health care like any other market, there will likely be very limited cost savings, if any, and huge inequities will continue and likely increase. As Nancy Tomes puts it, “this linguistic transformation has come to represent the worst consequences of American medicine’s growing market orientation.

The High Cost of US Health Care Is Not Due To Excessive Consumer Demand

Policy makers in the US frequently act as if the main problem is excess volume, which in turn arises from excess patient demand. Because most patients in the US have some form of health insurance, they are insulated from the full cost of health care. Some commentators are concerned that there is a potential moral hazard, because insurance provides patients with an incentive to consume health care beyond the point at which marginal benefit equals marginal cost.

More than just a technical term, moral hazard is a concept that is normatively loaded. It suggests that health care spending is the result of policies that offer an incentive for bad behavior.

Moral hazard concerns suggest that the use of expensive hospitalizations, surgeries, and other interventions are shaped primarily by ability to pay. This perspective fails to recognize that most people consume such services only reluctantly. The use of these services is often driven by providers, not by patients. Indeed, academics and policy makers have expressed concern for decades about the reliance of the health insurance system on fee-for-service payments to physicians, hospitals, and other health care providers. Fee-for-service provides an incentive for physicians to deliver additional and more complex services than patients need (or more care than economists would view as efficient) because health care providers receive an additional payment for every additional service—and services that are viewed as more technically complex generate higher fees. In most countries outside the US, however, “provider-driven” demand is not countered by shifting costs to individual patients and asking them to control costs by acting as informed consumers in a marketplace. Instead, most countries rely on a combination of overall budget targets for health care services and systems of all-payer rate regulation in which national health insurance funds negotiate rates for hospital, physician, and other services with representatives from those professions. Because the US does not use the negotiating power of government to confront the power of providers, it pays higher prices for all medical goods and services than other countries do.

Not only is the use of market competition limited when it comes to asking patients to make efficient decisions about health care services and providers, but it also does not work well when it comes to making decisions about health insurance plans. Competition among health plans in the Medicare program was promoted as a method for reducing the costs of the program, but Medicare Advantage has not produced the intended savings. In fact, there has been some examination of choices made in Medicare Part D, suggesting that consumers do not necessarily make choices in their own best interests: Beneficiaries fail to select plans that provide better risk protection at lower cost. These findings are consistent with earlier work on choice overload and Medicare beneficiaries’ selection of health plans. The findings led economist Paul Krugman to exclaim that “‘consumer-based’ medicine has been a bust everywhere it has been tried.

While it is wise to help patients make more informed decisions about the costs of care and to grow in their ability to make quality comparisons across health systems, the main driver of health care costs is not consumer demand, but rather the introduction of new technologies and unwillingness on the part of US political leaders to regulate prices—or at least use government bargaining power as leverage to negotiate lower prices. The US relies on a system of uncoordinated payment by thousands of payers, many of which do not have the bargaining power necessary to drive down prices. This has resulted in high prices for medical services. Technological improvements in health care have driven increases in cost all over the world, but extraordinarily high prices and a refusal by government to regulate them or bargain them lower differentiate the US from other countries.

The Consumer Metaphor Could Erode Health Care Professionalism

Medical professionalism requires independent, discretionary judgment. Professionals do not simply do as they are told or requested but must act on the basis of knowledge, skill, and fiduciary obligations to patients’ well-being.

Hospitals must judge each case to find the right balance between patient and family preference and physician integrity. It seems reasonable to anticipate that as the consumer metaphor grows, physicians’ authority in these kinds of cases could erode to the point where they may become technicians doing what they are asked to do, but doing so against their own consciences.

Professionalism may also erode if physicians are more inclined to offer unproven treatments simply because patients demand them. If the customer is always right, self-restraint on the part of providers could erode.

Conclusion

After four decades of organized patient advocacy, US patients are still struggling to influence the health care decisions and policies that shape their lives. Conflating consumer approaches with authentically patient-centered approaches will exacerbate this gap. In health care delivery and health policy, a patient-centered approach affirms the ethical principles of respect for persons and justice while striving to make the health system more responsive to patients’ values and preferences. There are some patient-centered approaches, such as patient engagement and activation, that yield substantial improvements in health outcomes. Pursuing the sensible goal of creating a patient-centered health system will be undermined if consumer metaphors prevail. It is important for policy makers and health system leaders to be vigilant in distinguishing between these seemingly similar, but different, approaches. Patient-centered approaches aim to ensure clinical care that can meet patients’ preferences and needs. That is different from a consumer orientation calling on patients to be prudent purchasers of medical care services. The former approach empowers patients. The latter expects patients to solve society’s cost-containment challenges.

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

The authors are from the Hastings Center, a nonprofit bioethics research institute in New York. That is important to understand since the consumer-driven movement in health care has left out this one crucial element: ethics.

Advocates of consumer-driven health care have conflated the primacy of the patient with the patient-as-a-consumer metaphor, but the two have very little in common.

A discussion of this issue is very timely since legislation to enact a single payer Medicare for All program has been introduced in Congress. Elimination of financial barriers to care (deductibles and other cost sharing) is a fundamental feature of this model of reform. Consumer-driven models deliberately erect financial barriers to care in order to deter the use of health care services and thus reduce health care spending, but it does so at the cost of impairing access to beneficial health care services and potentially exposing patients to financial hardship. In sharp contrast, a well designed single payer model uses much more patient-friendly methods of controlling spending. Specifically, costs are contained through publicly-administered negotiated pricing and global budgeting. Pricing is high enough to ensure adequate capacity in the system yet not excessive, thereby ensuring that health care will be available and affordable for society as a whole.

As the authors conclude, we should not expect patients to solve society’s cost-containment challenges. “Pursuing the sensible goal of creating a patient-centered health system will be undermined if consumer metaphors prevail.” Thus it is an ethical imperative to reject consumer-driven health care and move forward with an equitable, affordable system that ensures essential health care for everyone – Single Payer Medicare for All.

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Is Single-Payer Health Care a Pipe Dream?

By Elizabeth R. Rosenthal, M.D.
New York Times, Letters, March 5, 2019

To the Editor:

In the near future Medicare for all will join the heap of other impossible dreams that came true: women’s suffrage, Social Security, Medicare, integration and gay marriage.

All we need are bold leaders with imagination and a strong grass-roots movement to support them. They are on their way!

Dr. Rosenthal, a retired dermatologist, is on the board of Physicians for a National Health Program-NY Metro Chapter.

https://www.nytimes.com…

PNHP’s Adam Gaffney educates Fox Business panel

U.S. should transition to single-payer health care system: Dr. Adam Gaffney

Fox Business, March 1, 2019

Physicians for a National Health Program President Dr. Adam Gaffney discusses why the U.S. should move to single-payer health care system.

Nine minute Fox video:
https://video.foxbusiness.com…

Comment:

By Don McCanne, M.D.

Considering that most of the Fox panel members were more intent on providing their own right-wing messages against single payer health care, PNHP President Adam Gaffney is quite effective in giving quick, succinct responses on Medicare for All even as he has to override the squawking Fox magpies as they try to disrupt him.

Great job, Adam.

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