By Maria Caspani
Reuters, June 15, 2018

For over a year now, Americans have listed healthcare as the most important problem facing the country, according to Reuters/Ipsos polling.

When asked what concerns them about U.S. healthcare, this is what they had to say:

Total cost of health insurance

Sixty-five percent of Americans said in the poll that they are “very concerned” about the overall cost of health insurance, including premiums, deductibles and copays.

This concern is consistent throughout the country: A majority of both millennials and baby boomers, whites and minorities, Democrats and Republicans were worried about healthcare costs.

Prescription drugs

Nearly three in four Americans use prescription drugs, and 58 percent said they are “very concerned” about the cost of paying for them, according to the Reuters/Ipsos poll. These drugs are expected to see the fastest annual growth over the next decade, rising an average of 6.3 percent per year, according to the U.S. Centers for Medicare and Medicaid Services (CMS).

Choosing care

Sixty-six percent of U.S. adults who took part in the survey said they were concerned about their ability to see a doctor of their choice going forward.

Medicare and Medicaid

About one in three U.S. adults said they were “very concerned” about losing benefits from government-run programs Medicare and Medicaid.

Enrollment in Medicare is expected to increase as baby-boomers reach retirement age, according to CMS projections, which will contribute to growing healthcare spending.

The poll also showed that 58 percent of Americans think Congress should keep the Affordable Care Act either entirely as it is, or with some fixes, while 24 percent think lawmakers should repeal it once an alternative law is passed and 18 percent want the ACA to be repealed immediately.

The Reuters/Ipsos poll surveyed 3,982 people in English in the United States from May 22 to June 3 and it has a credibility interval of about 2 percentage points.

https://www.reuters.com…

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Comment:

By Don McCanne, M.D.

Plenty of polls confirm the concern of Americans over high health care costs. This new Reuters/Ipsos poll provides some specifics that should be seriously considered as we address our health care cost concerns.

Two-thirds of Americans throughout all sectors – millennials, baby boomers, whites, minorities, Democrats, Republicans – are worried not just about health care costs in general but specifically about insurance premiums, deductibles and copays. It seems that the private insurance model of financing health care does raise significant concerns about affordability. People have to realize that it doesn’t have to be that way.

Three-fourths of Americans use prescription drugs, and 58 percent say they are very concerned about the cost of paying for them. We need a better system of financing prescription medications.

Two-thirds of U.S. adults say they are concerned about their ability to see a doctor of their choice going forward. Although supporters of narrow provider networks contend that patients are quite willing to accept network restrictions in exchange for lower premiums, limiting choice of physicians is nevertheless a real concern for the majority. If we had an automatic, equitable method of financing health care that would eliminate the need for premiums, deductibles and copays, and did not need to rely on provider networks for cost containment, then certainly everyone would demand to have their choice of health care professionals and hospitals.

One-third of adults are very concerned about losing benefits under our government-run programs – Medicare and Medicaid. Concerns would likely be even less if we were all unified under an improved Medicare that covered everyone. The political support would be greater than it already is for our Medicare program, making a Medicare for all less vulnerable to political chicanery. Demonstrating how strong that support is, Speaker Paul Ryan just abandoned his career-long dream of diminishing the role of Medicare because he could not break through the political support it has.

The poll shows that 58 percent of Americans support keeping the Affordable Care Act entirely as it is or with some fixes. As is true of many polls, this is an incomplete question. It is designed to elicit support or opposition to the Affordable Care Act, but it does not offer the specific option of replacing ACA with a single payer improved Medicare for all. Other polls have repeatedly confirmed the very strong support for such a model of reform.

Yet much of the media seems to think that the options available are to repeal portions of the Affordable Care Act as the Republicans would do, or to add a public option or Medicare buy-in as perhaps the Democrats would do. But these options would leave in place those concerns demonstrated by this poll – high premiums, deductibles and copays, high drug costs, loss of choice of health care professionals, and political vulnerability of our existing public programs.

What most people really want is a lifelong guarantee of affordable, accessible health care such as would be found in an improved Medicare for all. We have to intensify our education efforts until we reach a threshold wherein people fully understand that it is our current dysfunctional financing model that is at fault so that they will reject being limited to only pro-ACA or anti-ACA choices and instead demand an improved Medicare for all.

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MedPAC – Medicare Payment Advisory Commission, June 2018

Chapter 10: Medicare coverage policy and use of low-value care

Chapter summary (excerpts)

Some researchers contend that a substantial share of Medicare dollars is not spent wisely. Many new services disseminate quickly into routine medical care in fee-for-service (FFS) Medicare with little or no basis for knowing whether or to what extent they outperform existing treatments. In addition, there is substantial use of low-value care—the provision of a service that has little or no clinical benefit or care in which the risk of harm from the service outweighs its potential benefit.

In this chapter, we review the coverage processes used in FFS Medicare and by Medicare Advantage (MA) plans and Part D sponsors. FFS Medicare covers many items and services without the need for an explicit coverage policy. When an explicit coverage policy is required, some services do not show that they are better than existing covered services. Coverage policies are often based on little evidence and usually do not include an explicit consideration of a service’s cost-effectiveness or value relative to existing treatment options.

MA plans are generally required to provide the same set of benefits that are available to beneficiaries under FFS Medicare. However, MA plans are permitted to use tools that are not widely used in FFS Medicare, such as requiring providers to obtain prior authorization to have a service covered and controlling utilization through the use of cost sharing. Part D plan sponsors are responsible for creating and managing formularies, which are lists of drugs their plans cover. By contrast, Medicare FFS lacks the flexibility to use formularies for drugs that Part B covers.

We also review the literature on low-value care, which reveals that such care is prevalent across FFS Medicare, Medicaid, and commercial insurance plans. Evidence suggests that the amount of low-value care in a geographic area is more a function of local practice patterns than payer type.

We analyzed selected low-value services in FFS Medicare using 31 evidence-based measures. In 2014, there were between 34 and 72 instances of low-value care per 100 beneficiaries, depending on whether we used a narrow or broad version of each measure. Between 23 percent and 37 percent of beneficiaries received at least one low-value service, and annual Medicare spending for these services ranged from $2.4 billion to $6.5 billion. The spending estimates are conservative because they do not reflect the downstream cost of low-value services (e.g., follow-up tests and procedures).

We discuss six tools that Medicare could consider using to address the use of low-value care.

* Expanding prior authorization, which requires providers to obtain approval from a plan or payer before delivering a product or service, could help reduce the use of low-value care.

* Implementing clinician decision support and provider education could decrease low-value care.

* Increasing cost sharing for low-value services has the potential to reduce their use.

* Establishing new payment models that hold providers accountable for the cost and quality of care—such as accountable care organizations (ACOs)—creates incentives for organizations to reduce low-value services.

* Revisiting coverage determinations on an ongoing basis has the potential to both decrease use of low-value services and result in the development of more rigorous clinical evidence.

* Linking information about the comparative clinical effectiveness and cost- effectiveness of health care services to FFS coverage and payment policies has the potential to improve the value of Medicare spending. For most items and services, Medicare lacks statutory authority to consider evidence on cost-effectiveness in either the coverage or the payment process.

Chapter 10:
http://medpac.gov…

Fact sheet on the 2018 MedPAC Report to Congress:
http://medpac.gov…

***

Comment:

By Don McCanne, M.D.

When concerns are expressed about the high costs of health care, frequently the excess use of low-value health care is cited as a major contributor to these high costs. MedPAC (Medical Payment Advisory Committee) in its 2018 report to Congress discusses its perception of the extent of the problem and potential policies that might reduce the overuse of low-value care. We should examine not only MedPAC’s views but also the larger perspective of cost containment in relation to improving health care value.

First of all, how do you define low-value care? Most would agree that care that is of no value whatsoever should not be covered by public or private insurance programs. But low-value? That seems to imply that the care may have very limited value, but does that mean that it should not be covered if the patient has medical needs and there is no better care available? Where do you draw the line?

We could probably agree that we should exclude from coverage care that is confirmed to have no benefit at all, care that might have very limited benefit but clearly always has greater detrimental effects, or care that clearly is always inferior to other less costly care. But in many instances, care that might be considered of low value should probably be covered. Often we do not have enough data to know the precise value of care, but we should avoid moving into the treacherous zone of micromanaging every health care decision. Regardless, it is much more difficult to objectively and fairly exclude low-value care from coverage than many in the policy community suggest. This is true not only in the United States but in all other health care systems as well.

So what policies does MedPAC suggest to reduce the use of low-value care? Let’s take a look.

* They suggest expanding prior authorization. Rather than being decided by those most acutely involved – the patient and the attending health care professionals – the decision is moved to a financial intermediary whose role is more often to protect the pooled health care funds that it is to improve resource allocation to benefit the patient. Not only does prior authorization waste administrative resources, it also results in a definitive decision when the potential benefit lies somewhere along a linear scale. What point do you select in that scale to come to an all or none conclusion on health care? That point should be pretty close to zero which then makes most of the prior authorization process a bureaucratic boondoggle. Besides, prior authorization is a significant source of patient discontent and a major contributor to health professional burnout – neither of which should be part of a high performance health care delivery system.

* They suggest implementing clinician decision support and provider education. More valid information is always helpful. Accumulating data and developing and improving patient care algorithms are always helpful. Some criticize this as “cookbook medicine,” but that is nonsense. The more information the better. These protocols and algorithms are most appropriately used as helpful guidelines rather than as dictates of a rigid bureaucracy. This is what the science and art of medicine always has been and should continue to be in the future as we constantly refine our standards.

* They suggest higher patient cost sharing for low-value care in order to deter the patient from receiving such care. However it would be very difficult to quantify just what the cost sharing should be since low value lies along a linear scale rather than occupying one point. More importantly, cost sharing impairs access to care and if care is appropriate, even if of low value, it should be covered. Financial barriers should be removed so patients can receive the care they should have. Other more effective methods of cost containment that are more patient friendly should be used instead of cost sharing (e.g., reduction of administrative waste, administered pricing, etc.).

* They suggest establishing new payment models that hold providers accountable for the cost and quality of care, such as accountable care organizations (ACOs). We now have fairly extensive experience with accountable care organizations and other alternative payment models that demonstrate they they are not particularly effective. They have had only a minimal impact on spending, sometimes to the detriment of patients, and the quality parameters are too inadequate to objectively demonstrate any significant systemic quality improvement. More voices are now calling for an end to this failed experiment.

* They suggest revisiting coverage determinations on an ongoing basis. As new information regarding the value of care becomes available, continuing reevaluation of current practices is certainly in order so that changes can be made in recommendations that improve care and its value. If low-value care proves to be no value care then it should be eliminated from coverage, and vice versa.

* They suggest linking information about the comparative clinical effectiveness and cost effectiveness of health care services to FFS coverage and payment policies. This is where we have been too protective of the medical-industrial complex. We should increase our research in comparative effectiveness and use that information to improve patient care. We should also demand that high priced care and products be repriced at a level deemed to be cost effective. Although the level may be relatively arbitrary, it’s clear that we shouldn’t be paying half a million dollars for a health outcome gain that some may judge to be worth only ten cents. Cost effectiveness determinations should be used to terminate outrageous pricing.

So we can conclude that care that is beneficial, even if only modestly so, should be covered, and it should be priced right.

That leaves us with a decision of how we could accomplish the goal of improving value in health care without exposing patients to potential financial hardship though the misguided application of consumer-directed care. Single payer advocates know the answer. Instead of reducing beneficial health care services through financial barriers, we should recover the large amount of waste inherent in our health care financing system: profound administrative excesses, and excessive pricing.

By changing to a single payer national health program – an improved Medicare for all – we could recover a few hundred billion dollars in administrative waste. Since our health care prices are often too high, we could reduce them over time to levels that would provide adequate value while ensuring fair margins for the health care delivery system. The funds recovered would be enough to ensure that all of us would receive the health care services that we should have – better care and better value for everyone.

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AMA House of Delegates 2018 Annual Meeting, June 9-13, 2018

Resolution 108

Introduced by: Medical Student Section

Subject: Expanding AMA’s Position on Healthcare Reform Options

Referred to: Reference Committee A

Excerpts

Whereas, Current AMA Policy H-165.847 establishes that comprehensive health system reform achieving quality healthcare for all Americans is of the highest priority to our AMA; and

Whereas, Our AMA is limited in its ability to engage in open and honest debate about all health care reform options via its blanket opposition to single payer financing mechanisms (AMA Policy H-165.838); and

Whereas, Evidence suggests that our AMA’s stance on single payer does not currently represent the majority of physicians, with two recent surveys by the Merritt Hawkins and the Chicago Medical Society each reporting a majority of physicians either strongly or somewhat supporting the concept of a broadly labeled single payer health care system; and

Whereas, Several US senators have recently supported legislation to move forward with a national single-payer health care financing reform, and as such our AMA must be equipped to have open, productive discussions on the matter in the coming years; and

Whereas, H.R. 676 – Expanded & Improved Medicare For All Act – has 122 cosponsors, and as such will likely come to the AMA for debate in the near future; therefore be it

RESOLVED, That our AMA rescind HOD Policy H-165.844; and be it further

RESOLVED, That our AMA rescind HOD Policy H-165.985; and be it further

RESOLVED, That our AMA amend HOD Policy H-165.888 by deletion as follows:

Delete: “B. Unfair concentration of market power of payers is detrimental to patients and physicians, if patient freedom of choice or physician ability to select mode of practice is limited or denied. Single-payer systems clearly fall within such a definition and, consequently, should continue to be opposed by the AMA. Reform proposals should balance fairly the market power between payers and physicians or be opposed.”

RESOLVED, That our AMA amend HOD policy H-165.838 by deletion as follows:

Delete: “12. AMA policy is that creation of a new single payer, government-run health care system is not in the best interest of the country and must not be part of national health system reform.”

https://www.ama-assn.org…

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Report of Reference Committee A

Excerpt

Your Reference Committee heard mixed testimony on Resolution 108. A member of the Council on Medical Service recommended reaffirmation of existing policy in lieu of Resolution 108, and shared the Council’s belief that the current approach of our AMA’s policy to health reform is the right one – emphasizing pluralism, freedom of choice, freedom of practice and universal access to patients. Another Council member noted that the Council has already studied international approaches to single payer. Testimony on both sides was passionate. Testimony in opposition raised concerns that Resolution 108 would open the door to the AMA supporting single payer, while testimony in support of the resolution noted the changes to policy outlined in the resolution would enable the AMA to participate in legislative discussions addressing single payer. An amendment was also offered to call for a study. Your Reference Committee underscores that this issue is highly complicated, and there is a need to examine AMA policy addressing health reform and single payer, study the pros and cons of single payer and alternative approaches to universal coverage, and study the impacts of single payer systems on physician practices and patients. As such, your Reference Committee recommends that Resolution 108 be referred.

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HOD ACTION: Resolution 108 referred.

https://www.ama-assn.org…

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Comment:

By Don McCanne, M.D.

The Medical Student Section of the American Medical Association is to be commended for advancing the consideration of single payer health care reform. Until now, the AMA has been consistently opposed to single payer. Resolution 108 calls for the AMA to expand its consideration of health care reform options by including single payer in its deliberations.

Although the resolution striking single payer opposition from AMA policies was not adopted at this time, rather than recommending that it be rejected, the reference committee recommended that it be referred to the AMA Board of Trustees for further consideration. In the words of the reference committee, “there is a need to examine AMA policy addressing health reform and single payer, study the pros and cons of single payer and alternative approaches to universal coverage, and study the impacts of single payer systems on physician practices and patients.”

The recommendation to refer was approved by the AMA House of Delegates.

This could be historic, and the thanks go to the medical students.

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By Teresa Seeman, Duncan Thomas, Sharon Stein Merkin, Kari Moore, Karol Watson, and Arun Karlamangla
PNAS – Proceedings of the National Academy of Sciences, March 27, 2018

Abstract

Longitudinal, individual-specific data from the Multi-Ethnic Study of Atherosclerosis (MESA) provide support for the hypothesis that the 2008 to 2010 Great Recession (GR) negatively impacted the health of US adults. Results further advance understanding of the relationship by (i) illuminating hypothesized greater negative impacts in population subgroups exposed to more severe impacts of the GR and (ii) explicitly controlling for confounding by individual differences in age-related changes in health over time. Analyses overcome limitations of prior work by (i) employing individual-level data that avoid concerns about ecological fallacy associated with prior reliance on group-level data, (ii) using four waves of data before the GR to estimate and control for underlying individual-level age-related trends, (iii) focusing on objective, temporally appropriate health outcomes rather than mortality, and (iv) leveraging a diverse cohort to investigate subgroup differences in the GR’s impact. Innovative individual fixed-effects modeling controlling for individual-level age-related trajectories yielded substantively important insights: (i) significant elevations post-GR for blood pressure and fasting glucose, especially among those on medication pre-GR, and (ii) reductions in prevalence and intensity of medication use post-GR. Important differences in the effects of the GR are seen across subgroups, with larger effects among younger adults (who are likely still in the labor force) and older homeowners (whose declining home wealth likely reduced financial security, with less scope for recouping losses during their lifetime); least affected were older adults without a college degree (whose greater reliance on Medicare and Social Security likely provided more protection from the recession).

From the Discussion

Differences by age, educational attainment, and homeownership provide additional insights by exploiting two defining features of the GR. First, the collapse of the housing and stock markets resulted in dramatic declines in the wealth of those who owned housing and those who were invested in the stock market, including those invested through a retirement account. With homeownership at historically high levels and the shift out of company-provided retirement plans, many older adults were exposed to increases in economic insecurity that were both unanticipated and unprecedented in almost a century. Second, earnings opportunities of those in the labor market were negatively affected as the labor market froze, job insecurity spiraled, and real wages declined for many workers.

For those on medication, BP rose most for the younger cohort, irrespective of level of education, all of whom were more likely in the labor market and concerned about retirement in the coming years. BP also rose significantly for those in the older cohort who were better educated and so more likely invested in the stock market and owned their home (among the better educated, 78% owned their home but only 59% among the less educated owned their home). The effects were substantially and significantly smaller for one group on medication: those age at least 65 at the start of the GR who had not completed college. They are the least likely to be working and most likely to rely on Social Security for income rather than a retirement plan invested in the stock market; these people were, therefore, likely to be the least affected by the recession among the four demographic groups.

Patterns for glucose by education and homeownership for those not on medications are similar to the patterns for BP for those not on medication, with significant increases seen among the younger cohort, again irrespective of education or home- ownership. The pattern for glucose among those on medication differs from that for BP, with significant increases seen only among younger adults who do not have a college education and among older adults who own a home. These increases are very large: 11 to 15% relative to each individual’s prerecession trend, possibly reflecting the extent to which these groups were (i) more vulnerable with respect to glucose regulation, being on medication even before the recession, and (ii) among the most heavily impacted by (i) unemployment among the younger cohort [as unemployment rates climbed 16% for those who did not complete high school while never exceeding 5% for those who completed college] and (ii) housing market upheavals among the older cohort.

Our findings provide support for the hypothesis that the economic and social stresses associated with the GR had a deleterious impact on adult health as seen in increases in BP and glucose. Importantly, the patterning of the health changes shows that the worst of the health impacts is among subgroups likely more negatively impacted by the Great Recession: younger adults (who are most likely still in the labor force) and better educated older homeowners (who are most likely invested in the stock market as well as their home). Direct examination of homeownership confirms that older homeowners indeed had the largest increases in BP and glucose from pre- to post-GR. The smallest effects were seen for less educated and nonhomeowning older adults (i.e., those no longer in the labor force and without “investment” in the housing market).

http://www.pnas.org…

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Comment:

By Don McCanne, M.D.

It is not surprising that the stresses of the Great Recession resulted in worsened blood pressure and blood glucose levels in American adults. But when looking at the subgroups, this study reinforces the importance of our social insurance programs – Medicare and Social Security.

Younger adults were stressed by a decline in earnings opportunities because of the freezing of the labor markets, spiraling job insecurity, and a decline in real wages. Older homeowners with private retirement accounts experienced decline in their investments, including a decline in the value of their homes, at a time that they were nearing retirement. Not unexpected, their health parameters were worse.

Of great importance is the fact that the least affected were those over 65 without a college education and who had little decline in wealth because they did not own their homes and were not as dependent on investments in private retirement accounts. They were protected by Social Security and Medicare, demonstrating the stability (if not the generosity) of social insurance programs when compared to private, individual investments.

Obviously an improved Medicare for all would provide everyone with social insurance covering health care regardless of the status of our economy. Social Security could also be improved to ensure basic income when unemployed, disabled, or retired. This study confirms, once again, that social insurance is good for our health. Private investment is great, but it should be built on a solid foundation of social insurance.

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