By Atul Gawande
The New Yorker, November 12, 2018

My hospital had, over the years, computerized many records and processes, but the new system would give us one platform for doing almost everything health professionals needed—recording and communicating our medical observations, sending prescriptions to a patient’s pharmacy, ordering tests and scans, viewing results, scheduling surgery, sending insurance bills. With Epic, paper lab-order slips, vital-signs charts, and hospital-ward records would disappear. We’d be greener, faster, better.

But three years later I’ve come to feel that a system that promised to increase my mastery over my work has, instead, increased my work’s mastery over me. I’m not the only one. A 2016 study found that physicians spent about two hours doing computer work for every hour spent face to face with a patient—whatever the brand of medical software. In the examination room, physicians devoted half of their patient time facing the screen to do electronic tasks. And these tasks were spilling over after hours. The University of Wisconsin found that the average workday for its family physicians had grown to eleven and a half hours. The result has been epidemic levels of burnout among clinicians. Forty per cent screen positive for depression, and seven per cent report suicidal thinking—almost double the rate of the general working population.

Something’s gone terribly wrong. Doctors are among the most technology-avid people in society; computerization has simplified tasks in many industries. Yet somehow we’ve reached a point where people in the medical profession actively, viscerally, volubly hate their computers.

Human beings do not only rebel. We also create. We force at least a certain amount of mutation, even when systems resist. Consider that, in recent years, one of the fastest-growing occupations in health care has been medical-scribe work, a field that hardly existed before electronic medical records. Medical scribes are trained assistants who work alongside physicians to take computer-related tasks off their hands. This fix is, admittedly, a little ridiculous. We replaced paper with computers because paper was inefficient. Now computers have become inefficient, so we’re hiring more humans. And it sort of works.

The story of modern medicine is the story of our human struggle with complexity. Technology will, without question, continually increase our ability to make diagnoses, to peer more deeply inside the body and the brain, to offer more treatments. It will help us document it all—but not necessarily to make sense of it all. Technology inevitably produces more noise and new uncertainties.

https://www.newyorker.com…

Comment:

By Don McCanne, M.D.

Almost no one should be surprised by Atul Gawande’s observations on the physicians’ role in the use of computerized medical records. The trade-offs have been almost unbearable. He discusses the solution of using medical scribes, yet “research has found error rates between twenty-four and fifty per cent in recording key data.”

Although he says that the use of scribes “sort of works,” that really isn’t a satisfactory solution. Does anyone think that Gawande will do much better as he crafts the Bezos/Buffett/Dimon-sponsored solution to the problems with our health care system? At least it seems clear that we should not take a wait-and-see approach before we decide to move forward with Single Payer Medicare for All. We should do that right now.

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

By Suzanne Gordon
Cornell University Press

The publisher’s book description:

U.S. military conflicts abroad have left nine million Americans dependent on the Veterans Health Administration (VHA) for medical care. Their “wounds of war” are treated by the largest hospital system in the country—one that has come under fire from critics in the White House, on Capitol Hill, and in the nation’s media. The resulting public debate about the future of veterans’ health care has pitted VHA patients and their care-givers against politicians and policy-makers who believe that former military personnel would be better served by private health care providers.

This high stakes controversy led Suzanne Gordon, award-winning health care journalist and author, to seek insight from veterans and their families, VHA staff and administrators, advocates for veterans, and proponents of privatization. Gordon spent five years closely observing the VHA’s treatment of patients suffering from service related injuries, physical and mental.

In Wounds of War, Gordon describes how the VHA – tasked with a challenging patient population – does a better job than private sector institutions offering primary and geriatric care, mental health and home care services, and support for patients nearing the end of life. The VHA, Gordon argues, is an integrated health care system worthy of wider emulation, rather than piece-meal dismantling for the benefit of private contractors. In the unusual culture of solidarity between patients and providers that the VHA has fostered, the author finds a working model for higher quality health care and a much-needed alternative to the practice of for-profit medicine.

Brief excerpts from the book, “Wounds of War”:

In this book I focus on how the VHA accomplishes its multiple missions and functions differently from its private-sector counterparts, whose care delivery is more costly, fragmented, and market-driven. As the largest health care system in the country, the VHA has its share of problems. But overall, as the studies and experiences I will cite convey, the VHA provides high-quality care to a very complicated patient population.

Several years ago, when I was visiting the VA Medical Center in West Haven, Connecticut, where my daughter worked, I joined a meeting with visiting staff from the UK’s National Health Service. The assembled British doctors, nurses, psychologists, social workers, and administrators had just trooped through one of the most prestigious teaching hospitals in the United States, the nearby Yale New Haven medical center. They were clearly grappling with the contradictions of what they had just seen. At a well-endowed institution, patients arrived in the emergency room with no insurance, they were discharged prematurely, medical specialists commanded huge salaries unheard of in their own country, primary care seemed undervalued, inter-professional training was spotty, caregivers of all kinds had no union voice, and coordination of care was, well, not exactly “world class.”

And then the UK delegation toured the veterans’ hospital just a few miles away from Yale New Haven. As they sat with VHA caregivers afterward, asking questions and exchanging information in a government-issue conference room, the same realization sank in: they had finally landed in a system – an actual system in the United States – that worked much like their own back home. One doctor finally asked the question on every visitor’s mind. “Why,” he wondered out loud, “do you have to be a military veteran to get this level of care in America? Why isn’t it available to all Americans?” Why indeed.

http://www.cornellpress.cornell.edu…

Unreliable Sources: How Corporate Funders Influenced Mass Media Coverage of Veterans’ Healthcare

By Suzanne Gordon and Jasper Craven
Veterans Healthcare Policy Institute

Phoenix is where today’s deep disdain of the VA first germinated. In the summer of 2014, evidence emerged that administrators at the VA Phoenix hospital had tampered with scheduling data, leaving veterans to wait months for an appointment. The scandal spurred passage of the Veterans Access, Choice and Accountability Act, which made it much easier for veterans to seek care in the private sector, and ignited a deeply divisive national debate over the government’s ability to deliver health care.

When the Phoenix scandal broke, Concerned Veterans for America (CVA) was a fledgling advocacy group working from the fringes. As the Washington Monthly reported, the group’s staff – led by telegenic veteran Pete Hegseth – brilliantly packaged, framed and fed the Phoenix story to a salivating news media desperate for a scandal in the Obama administration. The most serious charges out of Phoenix – that veterans died because they were unable to access care – were never substantiated. The cover up of wait times was more indicative of the agency’s chronic capacity and funding challenges than anything else – issues that to this day have not been meaningfully addressed.

Today, CVA holds incredible sway in Washington. Numerous CVA officials have entered President Donald Trump’s White House, or his Department of Veterans Affairs. Hegseth is now an anchor on the president’s favorite morning news show, Fox & Friends. And the group has built an incredibly effective organizing and messaging apparatus.

What is left out of most coverage is the voices of veterans who have been helped by the VA, as are studies demonstrating the high quality of VA care or explaining the countless challenges of privatization.

The RAND Corporation has been studying VA care since at least the early aughts, and its findings have consistently given the VA high marks while warning that the private sector is unprepared to deal with the complex needs of veterans.

This year alone, RAND has released two comprehensive studies: one that documented the excellence of VA healthcare; the other which revealed the gross inadequacies of New York state’s private healthcare system to treat veteran patients. Neither report attracted serious media attention.

https://www.veteranspolicy.org…

Comment:

By Don McCanne, M.D.

Believe it or not, we have several individuals in our government who do not believe in government, but rather claim to believe that the private sector can always do things better. Right now the privatizers are taking advantage of a few problems that exist in the Veterans Health Administration (VHA), and they are attempting to switch more veterans’ services to the private sector. The media has been complicit in covering only the problems and leaving out the real story of the VHA. Suzanne Gordon’s thoroughly researched and highly credible book – “Wounds of War” – describes the phenomenal accomplishments of the VHA and what that means for our veterans with service-connected health care needs.

“Wounds of War” should be mandatory reading for all legislators and government administrators who really do care about the welfare of our veterans. At the same time, we all need to be aware of the distortion of the perception of the VHA caused by the selective reporting of the supposedly reliable media of only the problems, and nothing about the great care veterans are receiving. The disinformation campaign is so intense that even many of the veterans themselves believe that the VHA is bad everywhere except at the facility where they happen to be. Their view? “Don’t fire anyone here – everyone here is a great, dedicated caregiver, driven by their commitment to veterans. As for everywhere else, heads should roll.”

If a cockroach crawled across Leonardo da Vinci’s “The Last Supper” would the painting be condemned and sent to a flea market? No? Then why do they want to take comparable action against the VHA?

At the national PNHP meeting in San Diego this weekend, Saturday, November 10, Suzanne Gordon will be conducting a workshop on this topic. If you can’t make it, at least read her book. Even if you do go, read it anyway.

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

Notice of Proposed Rule Making

Department of the Treasury
Department of Labor
Department of Health and Human Services

Published in the Federal Register, October 29, 2018

Summary: This document sets forth proposed rules to expand opportunities for working men and women and their families to access affordable, quality healthcare through proposed changes to regulations under various provisions of the Public Health Service Act (PHS Act), the Employee Retirement Income Security Act (ERISA), and the Internal Revenue Code (Code) regarding health reimbursement arrangements (HRAs) and other account-based group health plans. (For simplicity, this preamble generally refers only to HRAs, but references to HRAs should also be considered to include other account-based group health plans, unless indicated otherwise.) Specifically, these proposed rules allow integrating HRAs with individual health insurance coverage, if certain conditions are met. The proposed rules also set forth conditions under which certain HRAs would be recognized as limited excepted benefits. Also, the Department of the Treasury (Treasury Department) and the Internal Revenue Service (IRS) propose rules regarding premium tax credit (PTC) eligibility for individuals offered coverage under an HRA integrated with individual health insurance coverage. In addition, the Department of Labor (DOL) proposes a clarification to provide plan sponsors with assurance that the individual health insurance coverage the premiums of which are reimbursed by an HRA or a qualified small employer health reimbursement arrangement (QSEHRA) does not become part of an ERISA plan, provided certain conditions are met. Finally, the Department of Health and Human Services (HHS) proposes rules that would provide a special enrollment period in the individual market for individuals who gain access to an HRA integrated with individual health insurance coverage or who are provided a QSEHRA. The goal of these proposed rules is to expand the flexibility and use of HRAs to provide more Americans with additional options to obtain quality, affordable healthcare. The proposed rules would affect employees and their family members; employers, employee organizations, and other plan sponsors; group health plans; health insurance issuers; and purchasers of individual health insurance coverage.

https://s3.amazonaws.com…

Administration Moves To Incentivize Health Reimbursement Arrangements

By Katie Keith
Health Affairs Blog, October 26, 2018

On October 23, 2018, the Departments of Health and Human Services, Labor, and Treasury issued a new proposed rule to expand the use of health reimbursement arrangements to fund access to health insurance and health care. The proposed rule was developed in response to President Trump’s executive order from October 2017 that directed the federal government to expand access to short-term, limited-duration insurance, association health plans, and health reimbursement arrangements (HRAs).

In the executive order, President Trump directed the Departments to “increase the usability of HRAs, to expand employers’ ability to offer HRAs to their employees, and to allow HRAs to be used in conjunction with nongroup coverage.” As expected by many health policy watchers, the new rule would reverse prior Departmental guidance by allowing HRAs to be used to fund both premiums and out-of-pocket costs associated with individual health insurance coverage.

The proposed rule would also create a new “excepted benefit HRA” option that employees could use to pay premiums for excepted benefits policies and short-term, limited-duration insurance policies.

From the Implications

The rule could lead the loss of coverage if employers stop offering group health plans in lieu of an HRA, and their employees do not accept the HRA or obtain other coverage. The rule could also affect individuals who currently qualify for and receive marketplace subsidies while working for an employer who does not offer health coverage. Under the proposed rule, the offer of an “affordable” HRA-IIHIC would make an employee ineligible to receive a premium tax credit. As a result, some employees could pay more for coverage under the HRA-IIHIC option than they were paying if they received a premium tax credit through the marketplace. Consumers may also face higher cost-sharing in the individual market relative to what they received through a group health plan, and the HRA-IIHIC option could impose higher administrative and compliance burdens on consumers who must navigate a seemingly new system.

Whether these changes would be good for the individual market risk pool remains to be seen and would depend largely on the risk profile of employees offered the new HRA-IIHIC option. The Departments repeatedly note the concern that expanding access to HRAs could lead to employers offering coverage options to employees in a way that discriminates based on health status. At one point, the Departments state their goal to “prevent large-scale destabilization of the individual market” through the proposed rule.

On the other hand, there is the possibility that employees who enter the individual market through an HRA-IIHIC would be healthier on average, which could lead to a better risk profile for the individual market, and thus lower premiums and an even more stable marketplace. This could be especially true if sicker employees hold on to their group health plans, which might be more comprehensive than individual market coverage.

Overall, the proposed rule comes at a seemingly odd time. In the preamble, the Departments describe the various market reforms and structure of the ACA as “intend[ed] to create a robust and competitive individual market, in part by ensuring that risk pools included both higher risk and lower risk individuals.” Given this, the Departments seem comfortable with incentivizing—or at least opening up the possibility for—employees to receive coverage through the individual market, thereby further expanding that market. They do so even as President Trump and senior political leaders continue to argue, as recently as yesterday, that the ACA and the individual market are deeply flawed and broken with “deteriorating market conditions.”

https://www.healthaffairs.org…

Comment:

By Don McCanne, M.D.

The Trump administration is now proposing expanding the use of health reimbursement arrangements (HRAs) with the intent of moving more individuals from employer-sponsored plans and into the individual market, fulfilling the administration’s ideological preference for competition in the private marketplace.

If you are really curious about the details of their proposal, you can read the couple hundred pages of the proposed rule, or the long article by Katie Keith, briefly excerpted above. But understanding this proposal is not the purpose of today’s message. Rather it is to get a glimpse of the bizarre machinations in health care by this administrations.

Without going into any of the boring details, they are greatly increasing the administrative complexity of health care financing through health reimbursement arrangements, employer-sponsored plans, and plans in the individual market – this by an administration that says that it wants to increase choice and competition, giving more freedom to individuals to exercise their choices in the marketplace.

Administrative complexity is one of the worst features of health care financing in the United States, and yet this administration continues to compound the problem, not only increasing the waste, but further disrupting the important insurance function of pooling risk as they continue to increase fragmentation in health care financing.

Right now they are celebrating CMS Administrator Verma Seema’s tweet: “this year’s scariest Halloween costume – a tee shirt emblazoned with ‘Medicare for All.'” She followed up with, “Did I get your attention? Good. Medicare for All isn’t a joke. It’s a multi-trillion dollar drain on the American economy that will bankrupt future generations. It’s government controlled health care that will strip choice away from millions. It’s a bad idea. And it IS scary.”

Seema Verma has the solution to our health care financing problems right in front of her in her own department, and she ridicules it. What’s really scary is leaving these people in charge.

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

Mark Farrah Associates, October 31, 2018

As of October 1, 2018, total Medicare Advantage (MA) membership stood at over 21 million, representing approximately 34% of the 63.3 million Americans eligible for Medicare. Medicare Advantage plans can either be acquired individually through direct purchase policies or through employer/group retiree programs, commonly known as Medicare Advantage Employer Group Waiver Plans (MA-EGWPs). Since the inception of Medicare Advantage in 2003, Individual MA policies have historically dominated the market as 17.1 million beneficiaries purchased MA plans as of October 1, 2018. However, despite a decrease over the years in the number of private sector employers offering retiree health benefits, membership trends in MA-EGWPs have demonstrated notable enrollment growth, especially within the past two years.

Since December 2017, employer-group Medicare Advantage enrollment has increased by over 443 thousand. In fact, over the past four years, group market enrollment has increased by approximately 1 million members, nearly a 125% increase in enrollment since December 2015. This brief provides insights about the current employer-group Medicare Advantage market and assesses membership trends over the past four years by carrier and state.

https://www.markfarrah.com…

Comment:

By Don McCanne, M.D.

The continued growth in enrollment in private Medicare Advantage plans should be of concern to those who support Single Payer Medicare for All. The privatized Medicare program would not be suitable for a single payer system for the obvious reason that it would be a multi-payer system using private sector insurance plans.

This report shows that there is even more rapid growth in Medicare Advantage Employer Group Waiver Plans (MA-EGWPs) – plans that are used for employer/group retiree programs. Locking retired employees into these plans would make it even more difficult to transition into Single Payer Medicare for All since retirees tend to be quite supportive and defensive of their health benefit programs.

Right now there is an intensive effort taking place to defer, perhaps forever, the enactment of Single Payer Medicare for All through a strategy to create a Medicare for Some by offering the purchase of Medicare as an option (a public option) for those currently not yet qualified for Medicare. It is highly likely that the public option will be private health plans comparable to the Medicare Advantage plans, just as the plans offered in the government exchanges under the Affordable Care Act are private health plans.

In the meantime, the traditional Medicare program is being neglected, likely by design, and, as such, it would be unsuitable for Single Payer Medicare for All without significant improvements. However, as the private Medicare Advantage plans become more pervasive within the system, there is great risk that the traditional Medicare program will be reduced to a Medicaid-style welfare program, if not entirely abandoned.

The more we accept these incremental changes such as the Medicare Advantage Employer Group Waiver Plans and the pending Medicare Advantage public option – Medicare for Some – the greater the likelihood that we will never see Single Payer Medicare for All. As a reminder, Single Payer Medicare for All corrects the major deficiencies in health care financing, making health care equitable, accessible, and affordable for everyone, whereas the Public Option Medicare for Some perpetuates our highly dysfunctional, fragmented, inequitable, and often unaffordable health care financing system and merely adds one more option that increases the administrative complexity of our system.

The Medicare Advantage Employer Group Waiver Plans may seem relatively benign and perhaps even an incremental benefit, but these creeping programs are locking in stone a privatized system that is not even worthy of the name “Medicare.” The longer we wait, and the more we tolerate creeping incrementalism, the less likely we’ll ever see Single Payer Medicare for All.

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

By Sam Baker
Axios, October 31, 2018

When you hear candidates talk about “Medicare for All,” what do you think they are proposing?

52% – Single-payer, universal, government-run
21% – Competitive, optional, government-run
24% – Neither

Which of the following health care options do you prefer?

34% – Single-payer, universal, government-run
33% – Competitive, optional, government-run
30% – Neither

Data: Survey Monkey online poll conducted Oct. 24-26, 2018 among 2,949 U.S. adults. Total margin of error is ±2.5 percentage points.

https://www.axios.com…

Comment:

By Don McCanne, M.D.

This new poll confirms that the label, “Medicare for All,” no longer refers exclusively to a single payer program that includes everyone, but, for many people, it refers to a competitive, multi-payer market of health plans that includes Medicare as an option (i.e., a public option). In fact, the polling indicates that just as many believe that they would prefer a competitive, multi-payer model of “Medicare for All” as would prefer a true single payer model of “Medicare for All” that actually includes absolutely everyone.

Single payer advocates understand the crucial distinction, though many of the public option advocates do not seem to understand the consequences of their choice. The single payer version of “Medicare for All” corrects the major deficiencies in health care financing, making health care equitable, accessible, and affordable for everyone. The public option version of “Medicare for All” perpetuates our highly dysfunctional, fragmented, inequitable, and often unaffordable health care financing system and merely adds one more option that increases the administrative complexity of our system. The differences are absolutely critical, but they are being glossed over by misuse of the “Medicare for All” label.

It is imperative that we educate the public as to the difference, but the labeling is a problem. “Single payer” is a somewhat wonkish term that often is still not well understood by everyone. In contrast, Medicare is a program that is almost revered, and most individuals can hardly wait until they are eligible to enroll in it. Although we have been using “Improved Medicare for All,” that does not distinguish it from a “Medicare for All” that supposedly has been improved by adding a public option.

Until there is a consensus on precisely how we should proceed, I would suggest in the interim the two following measures:

1. We should keep the label simple, but to distinguish a bona fide single payer system, I would suggest calling it “Single Payer Medicare for All.”
2. When others use “Medicare for All” when they mean only adding a public option, always call them on it. Insist that they label their model “Medicare for Some,” explaining that they are proposing Medicare for a few more but not for most of us who would still have to deal with the current dysfunctional system.

At the PNHP annual meeting November 9 & 10 in San Diego there will be a workshop on “Faux single-payer plans and legislative deficiencies,” presented by David Himmelstein and President-elect Adam Gaffney. Maybe we can reach a consensus on our strategy at that time.

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

By Kip Sullivan
October 30, 2018

That was an excellent Quote of the Day, Don.

I want to emphasize the difference between what you and Alfie Kohn (the author of the NY Times essay) said, and what the RAND study authors said. You and Kohn said, “No more tinkering with P4P schemes, they don’t work, they make things worse.” The RAND study authors said, “Let’s keep tinkering, we can make P4P better.”

Here’s Kohn’s conclusion: “By now it should be clear that the trouble doesn’t lie with the type of reward, the schedule on which it’s presented, or any other detail of how it’s done. The problem is the outdated theory of motivation underlying the whole idea of treating people like pets — that is, saying: Do this, and you’ll get that.” In other words, the diagnosis underlying the entire P4P fad was wrong to begin with (it wasn’t merely “outdated”), ergo, the recommended solution — giving doctors little food pellets when they pull on the right lever and taking food pellets away when they fail to pull on the right lever — can’t work.

The RAND study is a useful contribution to the literature on what tended to be called P4P schemes from about 2000 to 2010, and since 2010 is more often called “value-based purchasing” (VBP) (The most important P4P/VBP schemes today are ACOs, medical homes, bundled payment, and the MIPS program.) The RAND study is useful because the authors actually went to the trouble of speaking to doctors — y’know, the people who treat patients who must cope with the useless feedback created by the proliferating VBP schemes imposed upon them by public and private insurers. It’s very rare to see a study that seeks to present the views of the creatures in the Skinner box created by VBP advocates over the last two decades (the Leapfrog Group, MedPAC, the Patient-centered Primary Care Collaborative, what used to be called the Institute of Medicine, the Robert Wood Johnson Foundation, Elliott Fisher, Stephen Shortell, Atul Gawande, Peter Orszag, Ezekiel Emanuel, members of both parties in Congress, etc.) The RAND study tells us that the creatures in the VBP Skinner box are confused and unhappy, and want out.

But the recommendations of the RAND study are ridiculous. They’re ridiculous because RAND has apparently totally ignored the research, accurately summed up by Kohn and Don, to wit, no amount of tinkering can fix a problem that was diagnosed incorrectly. (I say “apparently” because I have read only the summary of the RAND study.) RAND recommends merely:

• reducing the rate at which Congress, Medicare and the insurance industry gin up more VBP schemes,
• giving doctors some extra dollars to buy more IT hardware and software from Cerner and Epic so they can, in theory, make more sense of the white noise in the Skinner box, and
• provide more “understandable performance data.”

These pathetic recommendations reflect profound confusion about (a) the cause of high US health care costs (it’s our high prices caused by administrative waste and galloping consolidation, not excessive volume triggered by the FFS payment method) and (b) the solution (we need a true single-payer system, not Bernie’s bill or any other bill that doubles down on VBP nostrums).

How did the VBP buffs and RAND get so confused about the correct diagnosis of the American health care crisis and the correct response? Who told them per capita US health care costs are double those of the rest of the world because American doctors (and only American doctors) are motivated by greed and, therefore, routinely cave into the FFS incentive to order unnecessary services? Who told them physician “merit” or “efficiency” (their cost and quality) can be measured so accurately that the Masters of the Skinner Box can send doctors precise signals — more food pellets for you, fewer for you — that will accurately tell doctors when they’re being inefficient and when they’re failing to exercise good medical judgement?

Quote of the Day of October 29, 2018 — “Payment models are stuck in carrots and sticks”:
https://www.pnhp.org…

Comment:

By Don McCanne, M.D.

Yesterday’s Quote of the Day message was too important to let it pass on without further comment. Government legislative and administrative officials and the policy community in both the public and private sector continue to lead us down the wrong pathway to reform. Their value-based purchasing models for health care reform (paying for value instead of volume) are failing because they are based on the incorrect assumption that physicians will repair our health care system if only they are presented with petty rewards or penalties. They completely miss the ethical and professional foundations of the science and art of medicine.

The RAND study is an important contribution because they actually looked at physicians and how they are responding to the current health care payment models. They showed that the models are increasingly complex, that they are changing at an accelerating pace, and that risk aversion is a consequence. The error that RAND makes is that they ignore their important findings and fall in line with the rest of policy community in recommending more of the same.

The article yesterday by Alfie Kohn shows us that the petty rewards or punishments of carrots or sticks, or success or failure of obtaining reward pellets from a Skinner box, “can never create a lasting commitment to an action or a value, and often they have exactly the opposite effect.” Value-based purchasing (MIPS, APMs, ACOs, etc.) reduces health care to a petty reward system that fails on goals of higher quality and lower costs, while creating harm, especially through physician burnout.

Yesterday’s Quote of the Day and today’s comments by Kip Sullivan present two rhetorical versions of the same concept just to be sure that everyone understands it: value-based purchasing is the wrong pathway to reform. Both will be posted on the PNHP website so that they will always be available to help educate others (https://www.pnhp.org/news/quote-of-the-day, Oct. 29 & 30, 2018).

After the midterm election the legislative proposals for Medicare for All will be undergoing refinement. We need to be sure that the architects are not deceived into thinking that the legislation needs updating by adding the flawed concepts of value-based purchasing. We cannot allow the ethics and professionalism of medicine to be replaced with the carrots, sticks, and Skinner box pellets of value-based purchasing.

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

By Mark W. Friedberg, et al.
RAND, October 24, 2018

This report, sponsored by the American Medical Association (AMA), describes how alternative payment models (APMs) affect physicians, physicians’ practices, and hospital systems in the United States and also provides updated data to the original 2014 study. Payment models discussed are core payment (fee for service, capitation, episode-based and bundled), supplementary payment (shared savings, pay for performance, retainer-based), and combined payment (medical homes and accountable care organizations). The effects of changes since 2014 in the Affordable Care Act (ACA) and of new alternative payment models (APMs), such as the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) Quality Payment Program (QPP), are also examined.

Key Findings

Payment models are changing at an accelerating pace

Physician practices, health systems, and consultants find it difficult to keep up with the proliferation of new models, with some calling for a “time out” to allow them to better adapt to current APMs.

Payment models are increasing in complexity

Alternative payment models have become increasingly complex since 2014. Practices that have invested in understanding complex APMs have found opportunities to earn financial awards for their preexisting quality — without materially changing patient care.

Risk aversion is more prominent among physician practices

Risk aversion among physician practices was more prominent. Risk-averse practices sought to avoid downside risk or to off-load downside risk to partners (e.g., hospitals and device manufacturers) when possible.

For full document (96 pages):
https://www.rand.org…

RAND press release:
https://www.rand.org…

***

Science Confirms It: People Are Not Pets

Research on the efficacy of rewards tells us that we can’t bribe others into doing what we want.

By Alfie Kohn
The New York Times, October 27, 2018

The field of social psychology is sometimes accused of doing no more than ratifying common sense, so it’s worth paying attention when its findings are genuinely surprising. Case in point: the discovery that when we are rewarded for doing something, we tend to lose interest in whatever we had to do to get the reward.

This outcome has been confirmed scores of times with all sorts of rewards and tasks, and across cultures, ages and genders. Yet many teachers, parents and bosses persist in using versions of what has been called “sugarcoated control.”

Psychologists often distinguish between intrinsic motivation (wanting to do something for its own sake) and extrinsic motivation (for example, doing something in order to snag a goody). The first is the best predictor of high-quality achievement, and it can actually be undermined by the second. Moreover, when you promise people a reward, they often perform more poorly as a result.

Over the years, researchers have investigated some intriguing questions that stemmed from these basic findings. For instance: What if the reward is really large and luscious? (Answer: It’s apt to do even more damage to intrinsic motivation.) Are rewards destructive because they distract people from the task? (Apparently not, because other distractions don’t have the same negative effects.) Which is worse, giving people a set reward for doing something or making it contingent on how well they do it? (The latter, by a long shot.)

By now it should be clear that the trouble doesn’t lie with the type of reward, the schedule on which it’s presented, or any other detail of how it’s done. The problem is the outdated theory of motivation underlying the whole idea of treating people like pets — that is, saying: Do this, and you’ll get that.

The best that carrots — or sticks — can do is change people’s behavior temporarily. They can never create a lasting commitment to an action or a value, and often they have exactly the opposite effect … contrary to hypothesis.

https://www.nytimes.com…

***

Comment:

By Don McCanne, M.D.

There is much more here than a casual glance might imply. The search for value-based payment in health care, as opposed to paying for volume, has led to various payment models such as shared savings, accountable care organizations, bundled payments, pay for performance (P4P), medical homes, and other alternative payment models. How well is that working?

To date, most studies have been quite disappointing. Claims of cost savings are belied when considering the additional provider costs of information technology and human manpower devoted to these models, not to mention the high emotional cost of burnout. This RAND study shows that these models are increasing in complexity, making it difficult for the health delivery system to keep up. Even worse, they are inducing risk aversion. The health care providers are trying to avoid those who most need health care – the opposite of what our health care system should be delivering.

Much of the experimentation in delivery models has been centered around reward or punishment. But, as Alfie Kohn writes, “intrinsic motivation (wanting to do something for its own sake)… is the best predictor of high-quality achievement,” whereas “extrinsic motivation (for example, doing something in order to snag a goody)” can actually undermine intrinsic motivation. It has been observed by others that the personal satisfaction of achievement of patient health care goals is tremendously rewarding, whereas the token rewards based on meager quality measurements are often insulting because of the implication that somehow token payments are a greater motivator than fulfilling Hippocratic traditions. Even more insulting are the token penalties for falling on the wrong side of the bell curve simply as a result of making efforts to care for patients with greater medical or sociological difficulties.

Quoting Alfie Kohn again, “carrots or sticks… can never create a lasting commitment to an action or a value, and often they have exactly the opposite effect … contrary to hypothesis.” The RAND report suggests slowing down and working with these models some more while increasing investment in data management and analysis with the goal of increasing success with alternative payment models. No. These models are making things worse. It’s time to abandon them and get back with taking care of our patients. The payment model we need is an improved version of Medicare that takes care of everyone. Throw out the sticks and carrots.

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By Angela Hart
The Sacramento Bee, October 26, 2018

The union representing 100,000 nurses across California has shifted its “Medicare-for-all” campaign from California to the national stage, perhaps relieving political pressure on Democratic gubernatorial candidate Gavin Newsom to fulfill what the union sees as his top campaign promise: Delivering a single-payer health care system in the nation’s largest state.

The California Nurses Association, which led the coalition behind the high-profile 2017 push for a single-payer system, has re-branded its campaign with the slogan “Fight to Win Medicare-for-All!” Its social media feeds reflect the new national scope of their efforts.

Until this month, the coalition, previously called “Campaign for a Healthy California,” was focused solely on passing a single-payer health care bill in California. Their campaign reached a fervor in late 2017 and early 2018, when nurses and single-payer activists stormed the California Democratic Party convention and later, the state Capitol, calling on Democratic lawmakers to approve their single-payer bill.

Representatives for the union, joined by its parent organization, National Nurses United, are now expanding their efforts to Congress and other states, such as Florida, Maine, Minnesota and Texas. They say they’re not letting up in California.

“We’re not conceding or taking a loss here. There will be a single-payer bill next year,” said Stephanie Roberson, a spokeswoman for the California nurses union. “Our aim is to put strategic pressure on states where we see opportunities to provide health care for all, so we can make that national shift.”

“California is a starting point,” Roberson said.

Still, individual states face steep challenges in creating, within their borders, a new health care system that operates under a different set of rules and laws than the nation as a whole, said Gerald Kominski, a professor of health policy at the UCLA Center for Health Policy Research.

He said the nurses’ new efforts to apply pressure on Congress, and national candidates, could also be an acknowledgment that California can’t do it alone.

To create and pay for a single-payer system, under which the government would be the sole “payer” of health care services, California would need multiple approvals from the federal government to both collect federal health care dollars for the state-run system and to bypass regulations on employer-based private health plans. It would also have to amend the state Constitution.

“I think it’s the realization that developing a single-payer system at the state level faces significant legal barriers that maybe they’ve acknowledged…are more substantial than they were willing to admit publicly a year ago,” Kominski said. “It also might be a recognition that you’re pushing the next governor out too far on a limb, where you’re likely to be left hanging.”

Newsom has shifted his tone on single-payer, a system under which government, generally, becomes the primary payer of all health care services. Before the primary he said of single-payer: “It’s about time, Democrats.” He now says universal health care is the ultimate goal.

Nurses say they plan to hold Newsom accountable on his earlier comments and expect him sign a single-payer health care bill into law should he become governor. But their shift to a national focus could also be an opening to letting Newsom off the hook, Kominski said.

“Part of what this shows is the fight really does need to take place in Washington,” he said.

Holly Miller, a spokeswoman for the national nurses union, said the expansion into other states also aligns the push for a nationwide single-payer system, championed by Sens. Bernie Sanders and Kamala Harris.

“We did the re-branding of the social media feeds so we could show the much broader focus of the ‘Medicare-for-all’ campaign,” Miller said. “We’re using the movements in California and Florida to talk about the national fight. We’re for single-payer health care, whether we get it at the state level, or nationally.”

Newsom has acknowledged the political and financial challenges he’d face should he and others lawmakers decide to push for a single-payer system.

“We need partners in the federal government, so I’m not Pollyannaish about any of this. I’m a hard-headed pragmatist about it,” Newsom said in an interview last month.

Still, he said, “I do believe single-payer financing, as broadly defined in (a) “Medicare-for-all” type system, is an advantageous system compared to our multi-payer system, and I’m deeply engaged in figuring out the how…I’m not walking away from this.”

https://www.sacbee.com…

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Comment:

By Don McCanne, M.D.

This is not just another routine news report about Medicare for All advocacy. Rather it is a report of a milestone in the advancement of the single payer, Medicare for All movement, citing two of the most credible resources on the topic: 1) California Nurses Association/National Nurses United (CNA/NNU), and 2) UCLA Professor Gerald Kominski. Even the politically-guarded comments of the likely next governor of California – Gavin Newsom – provide valuable insight on the prospects for reform.

Although many Quote of the Day subscribers read just the comment (a wise time saver), this time I would suggest reading the lightly-edited Sacramento Bee article posted above. The nuances presented will hopefully calm down those who currently take a strong stand on whether single payer reform should be on a national or on a state basis.

I’ll step into it and say that the ultimate imperative remains a national improved Medicare for All. We want everyone throughout the nation in the system. Until that can be accomplished it is quite reasonable to do on a state level whatever can be accomplished to ensure that more people receive the health care that they should have.

If I were speaking instead of writing you would now hear me screaming as loud as I can that we cannot relax in the least with our mission to establish a national health program. State efforts must be in addition to and not in place of our national advocacy. CNA/NNU understands that. Gerald Kominski understands that. Gavin Newsom understands that. At PNHP it is even in our name: Physicians for a National Health Program.

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