Survey: 42% of Physicians Strongly Support a Single Payer Healthcare System, 35% are Strongly Opposed

By Phillip Miller
Merritt Hawkins, August 14, 2017

A plurality of physicians strongly support a single payer healthcare system, according to a new survey by Merritt Hawkins.

The survey of 1,033 physicians indicates that 42 percent strongly support a single payer health care system while 14 percent are somewhat supportive. Over one-third (35 percent) strongly oppose a single payer system while six percent are somewhat against it. The remaining three percent neither support nor oppose single payer.

The results contrast with a national survey of physicians Merritt Hawkins conducted in 2008, which indicated that 58 percent of physicians opposed single payer at that time while 42 percent supported it.

In Merritt Hawkins’ experience, there are four reasons why a growing number of physicians are in favor of single payer. First, they are seeking clarity and stability. The fits and starts of health reform and the growing complexity of our current hybrid system are a daily strain on most doctors. Many of them believe that a single payer healthcare system will reduce the distractions and allow them to focus on what they have paid a high price to do: care for patients.

Second, it’s a generational issue. The various surveys that Merritt Hawkins has conducted for The Physicians Foundation in the past show that younger doctors are more accepting of Obamacare, ACOs, EHR, and change in general than are older physicians As the new generation of physicians comes up, there is less resistance among doctors to single payer.

Third, there is a feeling of resignation rather than enthusiasm among some physicians about single payer. These physicians believe we are drifting toward single payer and would just as soon get it over with. The 14% of physicians surveyed who said they “somewhat” support single payer are probably in this group.

Fourth, there is a philosophical change among physicians that I think the public and political leaders on both sides of the aisle now share, which is that we should make an effort to cover as many people as possible.

However, while single payer has gained acceptance among some physicians, it remains strongly opposed by over one third and strongly or somewhat opposed by over 40 percent. It is still a polarizing issue among physicians and is likely to remain so for the foreseeable future.

Phillip Miller is Vice President of Corporate Communications for Merritt Hawkins.

https://www.merritthawkins.com…

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Kaiser Health Tracking Poll – August 2017: The Politics of ACA Repeal and Replace Efforts

Kaiser Family Foundation

READ TO ALL: As you may know, the 2010 Affordable Care Act created health insurance exchanges or marketplaces where people who don’t get coverage through their employers can shop for insurance and compare prices and benefits.

Q12. Thinking about President Trump and Republicans’ next steps on health care, which of the following do you think is more important for them to work on now? Should they work on (READ LIST)? (rotate response options 1-2/2-1)

69% – Fixing the remaining problems with the Affordable Care Act in order to help the marketplaces work better

29% – Continuing plans to repeal and replace the Affordable Care Act

2% – Something else (VOL.)

1% – Don’t know/Refused

http://files.kff.org…

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Comment:

By Don McCanne, M.D.

This Merritt Hawkins survey adds to the accumulated data that shows that a majority of physicians support a single payer system – 56 percent in this survey, with a 42 percent plurality strongly so. This demonstrates a significant increase in support compared to their last physician poll a decade ago.

Phillip Miller, Vice President of Corporate Communications for Merritt Hawkins, expresses the view that “there is a feeling of resignation rather than enthusiasm among some physicians about single payer.”

The current Kaiser Foundation Tracking Poll showed that, given a choice, 69 percent of the general public would prefer to fix “the remaining problems with the Affordable Care Act in order to help the marketplaces work better,” whereas 29 percent would prefer to continue plans “to repeal and replace the Affordable Care Act.” Only 2 percent volunteered “something else,” presumably including single payer. It appears that the current surge in support of single payer is not strong enough for those polled to voluntarily cite single payer as a preference to the options of either fixing ACA or repealing and replacing it.

Our physician colleagues and the public at large need to continue to hear our three messages until they become steadfast believers and activists for the cause: 1) In spite of the improvements, patching the Affordable Care Act will still leave us far short of an efficient, equitable, affordable health care system that is truly universal, 2) current repeal and replace proposals would make health care even less accessible and less affordable, and 3) single payer – an improved Medicare for all – would finally bring affordable care to absolutely everyone.

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

NBER Working Paper 23668: Subsidizing Health Insurance for Low-Income Adults: Evidence from Massachusetts

By Amy Finkelstein, Nathaniel Hendren, and Mark Shepard
National Bureau of Economic Research, August 2017

Abstract

How much are low-income individuals willing to pay for health insurance, and what are the implications for insurance markets? Using administrative data from Massachusetts’ subsidized insurance exchange, we exploit discontinuities in the subsidy schedule to estimate willingness to pay and costs of insurance among low-income adults. As subsidies decline, insurance take-up falls rapidly, dropping about 25% for each $40 increase in monthly enrollee premiums. Marginal enrollees tend to be lower-cost, consistent with adverse selection into insurance. But across the entire distribution we can observe – approximately the bottom 70% of the willingness to pay distribution – enrollee willingness to pay is always less than half of own expected costs. As a result, we estimate that take-up will be highly incomplete even with generous subsidies: if enrollee premiums were 25% of insurers’ average costs, at most half of potential enrollees would buy insurance; even premiums subsidized to 10% of average costs would still leave at least 20% uninsured. We suggest an important role for uncompensated care for the uninsured in explaining these findings and explore normative implications.

From the Introduction

Governments spend an enormous amount of money on health insurance for low-income individuals. For instance, the U.S. Medicaid program (at $550 billion in 2015) dwarfs the size of the next largest means-tested programs – food stamps and the EITC ($70 billion each). Perhaps because of these high and rising costs, public programs increasingly offer partial subsidies for health insurance, requiring enrollees to pay premiums to help cover costs. Partial subsidies are a key feature of market-based programs such as Medicare Part D and the Affordable Care Act (ACA) exchanges, and even traditional low-income programs like Medicaid and the Children’s Health Insurance Program (CHIP) increasingly require premiums for some enrollees. Partial subsidies are also a textbook policy response to adverse selection if a full coverage mandate may not be efficient.

In this paper, we estimate low-income individuals’ willingness to pay (WTP) for health insurance, assess how it compares to the cost they impose on the insurer, and discuss the positive and normative implications for subsidized health insurance programs. We do so in the context of Massachusetts’ pioneer health insurance exchange for low-income individuals, known as “Commonwealth Care” or “CommCare.” Established in the state’s 2006 health care reform, CommCare offered heavily-subsidized private plans to non-elderly adults below 300% of poverty who did not have access to insurance through an employer or another public program.

We first document two main descriptive patterns. First, enrollee demand is highly sensitive to premiums. With each discrete increase in enrollee premiums, enrollment in CommCare falls by about 25%, or a 20-24 percentage point fall in the take-up rate. Second, we find that despite the presence of a coverage mandate, the market is characterized by adverse selection: as enrollee premiums rise, lower-cost enrollees disproportionately drop out, raising the average cost of the remaining insured population.

We use a simple model to analyze the implications of these descriptive patterns.

The model allows us to translate the descriptive patterns into two main results about willingness to pay and costs for these plans. First, even large insurance subsidies are insufficient to generate near-complete take-up of insurance by low-income adults.

These findings suggest that even modest enrollee premiums can be a major deterrent to universal coverage among low-income people. This deterrent is likely to be even larger in the ACA exchanges, in which income-specific premiums are significantly higher than in CommCare.

Second, although adverse selection exists, it is not the primary driver of low take-up. The cost of marginal consumers who enroll when premiums decline is less than the average costs of those already enrolled, implying that plans are adversely selected. But across the in-sample distribution – which spans the 6th to the 70th percentile of the willingness to pay distribution – the willingness to pay of marginal enrollees still lies far below their own expected costs imposed on insurers for either the H or L plans. For example, for the median willingness to pay individual, the gap between the costs of the marginal enrollee and average costs of enrollees explains only one-third of the $300 gap between willingness to pay and average costs. This suggests individuals would not enroll even if prices were subsidized to reflect the expected cost of marginal enrollees. Enrollment is low not simply because of adverse selection, but because people are not willing to pay their own cost imposed on the insurer.

In the final section of the paper, we briefly explore potential explanations for our findings and analyze their normative implications. Back-of-the-envelope calculations using estimates from the prior literature suggest that moral hazard effects of health insurance cannot explain much of the gap between willingness to pay and costs. However, an estimate of the uncompensated care available to the uninsured suggests that this can account for nearly all of our estimated gap between willingness to pay and costs of insurance.

If we interpret our willingness to pay estimates normatively as individuals’ value of insurance, they suggest that most low-income enrollees would prefer being uninsured to having to pay the cost they impose on the insurer. This suggests that subsidies in this market cannot be justified simply as a response to adverse selection. Our results suggest two potential such justifications for subsidies: as an offset to the externalities resulting from uncompensated care (i.e., the Samaritan’s dilemma (Buchanan, 1975; Coate, 1995)), or as a means of redistribution to low-income households.

5.1 Why Is WTP so Low?

We estimate that willingness to pay is less than one-third of average costs. This cannot be fully explained by adverse selection driving a wedge between average costs and costs for marginal enrollees. We estimate that willingness to pay is also always less than half of marginal enrollees’ own expected costs. This stylized fact runs counter to a standard assumption in textbook models of insurance demand – that willingness to pay for insurance equals expected costs plus a value of risk protection.

In principle, moral hazard offers a potential explanation. If the provision of health insurance leads individuals to consume care they wouldn’t have consumed when uninsured (“moral hazard”), their willingness to pay for this additional care will be less than the cost they would have had to pay for it when uninsured. In practice, however, moral hazard is unlikely to be large enough to explain the results. Insurance would have to increase costs by a factor of at least 200% to explain the estimated gap between willingness to pay (Wj) and own costs (Cj). This seems well outside the plausible range of estimates.

By contrast, uncompensated care for the low-income uninsured is large enough to rationalize their low willingness to pay for CommCare. Uncompensated care for the uninsured reduces willingness to pay relative to the gross cost of this insurance, since some share of those costs pays for care that, if uninsured, would have been paid for by third parties. Estimates suggest that the uninsured pay only about 20% to 35% of their cost of care, which is remarkably similar to our estimated ratio of WTP to own costs for the H plan. Not surprisingly therefore, a simple back-of-the-envelope calculation suggests that the magnitude of uncompensated care for the low-income uninsured could close most of the gap between willingness to pay (WH) and own expected cost (CH).

A large role for uncompensated care also can potentially explain differential take-up findings for low- vs. high-income populations. The low willingness to pay we find for the low-income population in Massachusetts contrasts with the findings for higher-income individuals in Massachusetts: Hackmann, Kolstad, and Kowalski (2015) estimate that individuals above 300% of the federal poverty line in Massachusetts are willing to pay the (gross) cost they impose on the insurer. One parsimonious way to rationalize these findings is that only low-income individuals are able to obtain substantial uncompensated care, and this uncompensated care when uninsured reduces the willingness to pay for formal insurance.

From the Conclusion

This paper estimates willingness to pay and costs for health insurance among low-income adults using data from Massachusetts’ pioneer subsidized insurance exchange. For at least 70% of the low-income eligible population, we find that willingness to pay for insurance is far below insurers’ average costs. Adverse selection exists, despite the presence of the coverage mandate, but is not the driving force behind low take up. We estimate that willingness to pay is less than half of enrollees’ own expected costs; thus, even if insurers could set prices conditional on an individual’s willingness to pay, at least 70% of the market would be uninsured.

From a positive economics perspective, our results point to substantial challenges in getting to universal coverage via partially subsidized insurance programs like the ACA’s exchanges. For example, we estimate that even subsidizing premiums down to 10% of insurer costs would generate only 80% coverage. This reality may underlie the incomplete take-up of insurance under the ACA, despite a coverage mandate and generous subsidies. We provide suggestive evidence of an important role for uncompensated care in explaining why willingness to pay is substantially below (gross) insurance costs. This in turn suggests a potential economic rationale for subsidies as a response to the “Samaritan’s dilemma” to offset the implicit tax that uncompensated care imposes on formal insurance (Coate, 1995).

http://www.nber.org…

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Altruism, the Samaritan’s Dilemma, and Government Transfer Policy

By Stephen Coate
American Economic Review, 1995, vol. 85, issue 1, 46-57

Abstract

This paper shows that altruism provides an efficiency rationale for public provision of insurance to the poor. The framework is one in which there are rich altruists and risk-averse poor who face some possibility of loss. The government represents the rich and makes transfers on their behalf. With unconditional transfers, the poor may forgo insurance and rely on private charity to bail them out in the event of loss. This reliance on private charity has adverse efficiency effects. These may be avoided if the government makes in-kind transfers of insurance.

http://econpapers.repec.org…

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Distribution of the Nonelderly Uninsured by Federal Poverty Level (FPL) in 2015

Kaiser Family Foundation

26% – Under 100%

27% – 100%-199%

28% – 200%-399%

19% – 400%+

http://www.kff.org…

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Comment:

By Don McCanne, M.D.

Wading through this technical 56 page paper, the following understated observation may be the most important: “our results point to substantial challenges in getting to universal coverage via partially subsidized insurance programs like the ACA’s exchanges.” That is, using income related premium tax credits for plans in the ACA exchanges, even with an individual mandate, is a grave design defect because it can never get us to universal coverage.

This study looked at low-income individuals and showed that, not only did adverse selection result in individuals remaining uninsured, but a much greater factor was that the willingness to pay for a percentage of the premium is far below the insurers’ average costs. Even with 90% of the premium subsidized, 20% of the individuals would remain uninsured, and the percent insured dropped off rapidly as the individuals’ share increased.

The authors cite a reference that indicates that higher-income individuals are willing to pay the cost they impose on insurers. But lest we think that avoiding the purchase of insurance due to cost is limited to lower income individuals, that is refuted by the Kaiser Foundation report that shows that the uninsured are distributed throughout all income levels – 19% of them having incomes over 400% of the federal poverty level. Any proposed policy correction should not be limited to lower-income individuals.

The authors suggest that “only low-income individuals are able to obtain substantial uncompensated care, and this uncompensated care when uninsured reduces the willingness to pay for formal insurance.” The authors cite Coate in regard to the “Samaritan’s dilemma” as a rationale for subsidies, but Coate states, “The government represents the rich and makes transfers on their behalf. With unconditional transfers, the poor may forgo insurance and rely on private charity to bail them out in the event of loss. This reliance on private charity has adverse efficiency effects. These may be avoided if the government makes in-kind transfers of insurance.”

Providing highly technical studies such as this one from NBER advances the science on which we base our policy decisions, but it does not take an MIT economist to come to the conclusion that when a policy is not working, you need to change it. Even generous premium tax credits for ACA exchange plans can never get us to universal coverage, yet government making in-kind transfers of insurance will, providing we include all income levels and fund the program with income transfers through progressive taxation.

Again, subsidizing health insurance cannot ever get us to universal coverage. Single payer will.

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Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care

By Fumiko Chino, MD; Jeffrey M. Peppercorn, MD, MPH; Christel Rushing, MS; S. Yousuf Zafar, MD, MHS; et al
JAMA Oncology, August 10, 2017

The financial burden of cancer treatment is a well-established concern. Owing to cost sharing, even insured patients face financial burden and are at risk for worsened quality of life and increased mortality. Underinsured patients (those spending more than 10% of their income on health care costs) are a growing population, and are at risk given the looming heath policy and coverage changes on the horizon.

From the Discussion

More than one-third of insured cancer patients receiving anticancer therapy faced out-of-pocket costs that were greater than expected, and patients with the most distress were underinsured, paying almost one-third of their income in health care-related costs. Patients at risk for unexpected costs had less household income and faced higher out-of-pocket costs.

http://jamanetwork.com…

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Widowed Early, A Cancer Doctor Writes About The Harm Of Medical Debt

By Alison Kodjak
NPR, August 10, 2017

Ten years ago, Fumiko Chino was the art director at a television production company in Houston, engaged to be married to a young Ph.D. candidate.

Today, she’s a radiation oncologist at Duke University, studying the effects of financial strain on cancer patients. And she’s a widow.

“I think of him every day,” Chino says of her late husband, Andrew Ladd. “It drives me to do the type of research that I do — that’s looking at the financial toxicity of cancer care.”

Chino is co-author of a research letter, published Thursday in JAMA Oncology, that shows that some cancer patients, even with insurance, spend about a third of their household income on out-of-pocket health care costs outside of insurance premiums.

In 2005, before they were married, Chino and Ladd were living together in Houston. She was working in entertainment, and he was on the verge of earning his doctorate in robotics at Rice University. Each had medical insurance – she through her job, he through the school.

Then he started to vomit and lose weight.

He was diagnosed with neuroendocrine carcinoma, an aggressive cancer of endocrine cells that can strike in a variety of places in the body and can be hard to treat.

It was a huge blow for the young couple, still in their 20s, with promising careers ahead of them. Still, they looked to the future and decided to go ahead with their wedding.

But as Ladd’s treatment moved forward, a harsh reality hit. His student insurance didn’t cover much.

Soon, his medical costs surpassed his insurance policy’s $500,000 lifetime limit (before ACA). But the bills kept coming.

Even as insurance coverage has expanded (under ACA), deductibles and copays on many policies have risen, leaving patients to shoulder more of the financial burden for their health care.

“The stress and overwhelming crushing defeat of these bills that would come in every week — it had an effect on our quality of life,” Chino says.

Despite his illness, Ladd landed a job as a professor at the University of Michigan. It came with health insurance, and he continued treatment there.

But he never moved into his office. Three months into his time at Michigan, he died.

Chino was left with an ocean of debt. She estimates it’s in the hundreds of thousands of dollars.

That’s when she found a new mission in life. She enrolled in Duke’s medical school and teamed up with Dr. Yousuf Zafar, who has made a specialty out of studying and writing about “financial toxicity,” which he describes as the toxic effects of financial strain from health care costs. He’s lead author on the JAMA Oncology study that Chino worked on.

“Patients are frustrated,” Zafar says. “They believe they’ve got insurance. They believe they paid for insurance and that insurance should fully cover their cancer care.”

“We need to do a better job explaining to our patients how much benefit they can get from treatment,” he says. “But also how much harm they can face, whether that harm is physical toxicity or financial toxicity.”

Ten years after Ladd’s death, Chino is still dealing with the aftereffects.

“I still owe the debt,” she says. “I stopped answering phone calls from debt collectors.”

http://www.npr.org…

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Comment:

By Don McCanne, M.D.

Health care professionals who are health reform activists can certainly identify with the plight of radiation oncologist Fumiko Chino. Not only did she face the almost unbearable tragedy of her husband’s lethal cancer, she has been left with overwhelming medical debt in spite of insurance coverage.

Helping all of us to better understand the financial impact of cancer, Dr. Chino has co-authored an article in JAMA Oncology, “Out-of-Pocket Costs, Financial Distress, and Underinsurance in Cancer Care.” Her lead co-author, Dr. Yousuf Zafar, acknowledges what a problem “financial toxicity” is and suggests that we need to do a better job of explaining to patients not only the physical toxicity of cancer therapy but also the financial toxicity. (Pause…)

We certainly admire Dr. Zafar for his efforts to educate us on financial toxicity, but we really do need to move beyond just talking about it. Our health care financing system needs to be redesigned to remove financial barriers to care, and, further, when an individual is already suffering from impaired health, the last thing we need to do is to add financial hardship through medical debt.

It is no secret that a well designed single payer program would remove financial barriers to care and prevent medical debt. People would just get health care when they need it and not have to worry about how they would pay for it.

It will be a breakthrough when medical journal editors who publish articles on the problems of financing health care begin to request that the authors include a remedy for financial toxicity – one that has been proven beyond any doubt to be fully effective – a single payer national health program.

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

California talks big on health, but so few docs take Medi-Cal that it violates civil rights

By Bill Lann Lee
The Sacramento Bee, August 9, 2017

California draws praise for leading the country in many ways, but our state is faltering badly in an area that is vital to millions: healthcare for our most vulnerable residents.

Fully one-third of our population, including seniors, people with disabilities and children, depend on Medi-Cal, the Medicaid health insurance program for low-income Californians. While there is wide coverage, Medi-Cal recipients have worse access to healthcare than Medicaid recipients in almost every other state, judged by the percentage of physicians who accept Medicaid patients.

This means suffering for people who have health coverage but, in fact, can’t get care. Too often, Medi-Cal patients are told no doctors will treat them, must endure long delays in scheduling appointments, and are forced to travel long distances for care. Poor, disproportionately Latino Medi-Cal patients often are unable to access care they would receive if covered by other health insurance.

Our state’s payments are so low that they deter many providers from treating more than a few, if any, Medi-Cal patients, with physicians saying that Medi-Cal payments are far below their costs of providing care, whether in fee-for-service or managed care.

This not only endangers the health of millions of Californians, but as our state officials should know, it violates health and civil rights laws.

Why?

Today, Latinos are more than half of all Medi-Cal enrollees statewide. As Latino enrollment in the program surged, Medi-Cal’s relative reimbursement rates plummeted.

In 2000, Medi-Cal rates were about two-thirds of Medicare’s, but they have fallen to about half what Medicare pays. Meanwhile, the number of Latinos in Medi-Cal climbed from 2.3 million in 2000 to 7.2 million in 2016. California’s politicians cannot blame financial shortfall; this alarming trend of disinvestment continued whether the state budget was tight or flush.

Civil rights and healthcare laws require that Medi-Cal recipients have access to healthcare equal to people with other insurance, such as Medicare and employer-sponsored insurance. Our state health officials have been so resistant to improving this situation that my organization, the Civil Rights Education and Enforcement Center, joined the Mexican American Legal Defense and Educational Fund to challenge this inequality.

Making sure that Medi-Cal provides the access to health care for those it covers is simple justice.

Bill Lann Lee, former Assistant Attorney General for Civil Rights with the U.S. Department of Justice, is senior counsel at the Civil Rights Education and Enforcement Center.

http://www.sacbee.com…

Los Angeles Times editorial: Does state funding for Medi-Cal discriminate against the Latinos it serves?
http://www.latimes.com…

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Comment:

By Don McCanne, M.D.

Many proclaim that the greatest success of the Affordable Care Act was the 30 percent increase in Medicaid enrollment – now 74 million individuals. But Medicaid is a chronically underfunded welfare program, critically so in states like California.

One-third of Californians are enrolled in Medi-Cal (California’s Medicaid), and over half – 7.2 million – are Latinos. Access is impaired because of a lack of willing providers due to payments that are well below the costs of providing health care. Unequal access to care violates the civil rights of the Latinos enrolled in this program. More broadly, it establishes the principle that lower income individuals on Medicaid are not entitled to the same level of access to care as those with higher incomes covered by more traditional health insurance.

A single payer system would be much more egalitarian, ensuring as much as possible that care would be there for anyone who needs it.

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Federally Qualified Health Center Clinicians And Staff Increasingly Dissatisfied With Workplace Conditions

By Mark W. Friedberg, Rachel O. Reid, Justin W. Timbie, Claude Setodji, Aaron Kofner, Beverly Weidmer and Katherine Kahn (all from RAND)
Health Affairs, August 2017

Abstract

Better working conditions for clinicians and staff could help primary care practices implement delivery system innovations and help sustain the US primary care workforce. Using longitudinal surveys, we assessed the experience of clinicians and staff in 296 clinical sites that participated in the Centers for Medicare and Medicaid Services (CMS) Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration. Participating FQHCs were expected to achieve, within three years, patient-centered medical home recognition at level 3—the highest level possible. During 2013–14, clinicians and staff in these FQHCs reported statistically significant declines in multiple measures of professional satisfaction, work environment, and practice culture. There were no significant improvements on any surveyed measure. These findings suggest that working conditions in FQHCs have deteriorated recently. Whether findings would be similar in other primary care practices is unknown. Although we did not identify the causes of these declines, possible stressors include the adoption of health information technology, practice transformation, and increased demand for services.

From the Discussion

Our findings are consistent with reports of increasing burnout and declining professional satisfaction among physicians across the United States, not just in safety-net clinics. However, they differ with the only assessment of longitudinal changes in provider experience during a medical home initiative published to our knowledge, in which transformation within a single Group Health Cooperative site was associated with improvements in provider burnout between 2006 and 2008. This discrepancy might be explained by differences in time frame, type of clinic (FQHC versus integrated system), and intervention design (the Group Health pilot was motivated by and designed to mitigate provider burnout). Moreover, some FQHCs have high staff turnover, and most serve patients with complex medical, behavioral, and social needs—which can make practice transformation more difficult. The finding that top-of-license scores did not improve suggests that many FQHCs in our sample may have transformed only to a modest extent. Applying for and receiving medical home recognition could have been a higher priority than transformation. In addition, when safety-net clinics have insufficient staffing levels, this can increase the risk of burnout associated with quality improvement efforts.

Conclusion

Clinicians and other staff members working in a national sample of federally qualified health center sites reported declines over time in multiple measures of professional satisfaction, work environment, and practice culture. Our analysis could not identify the factors contributing to these declines. However, as additional health system changes accumulate under the Medicare Access and CHIP Reauthorization Act of 2016 and new legislative and regulatory activity, policy makers should consider further study of how these forces could affect primary care working conditions—especially in FQHCs and other safety-net clinics.

http://content.healthaffairs.org…

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Comment:

By Don McCanne, M.D.

Imagine the satisfaction it must bring to health care professionals to practice in an environment wherein you know that you are providing health care access to less fortunate individuals who might otherwise go without care. Furthermore, these Federally Qualified Health Centers were engaged in improving the delivery system in a manner that should increase satisfaction through attaining the highest status level of patient centered medical homes. Yet measures of professional satisfaction, work environment, and practice culture all declined in this study, resulting in provider burnout. What went wrong?

One observation might give us a clue. A similar prior effort to transform a Group Health Cooperative site into a medical home resulted in a decline in provider burnout. The authors report that “the Group Health pilot was motivated by and designed to mitigate provider burnout.” In contrast the various innovations taking place today are designed by bureaucrats and policy wonks largely based on widespread application of health policy theory flavored by ideology. They don’t get it.

Could single payer improve the situation? It could if the stewards were always keeping in mind what is best for the patient, and that includes ensuring the contentment of the health care workforce. A single payer system should automatically establish the presumption that this is all about improving the health of the patients and the community at large. It is not about providing a favorable business environment for the stakeholders even though that means perpetuating health care injustices such as lack of insurance, impaired access, financial hardship, health care inequity, and poorer health outcomes.

So one of the more important gifts of converting to a single payer system would be an improvement in attitude. We really need it.

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

Anthem BlueCross BlueShield, May 11, 2017

Save the ER for emergencies — Or you’ll be responsible for the cost

Going to the emergency room or calling 9-1-1 is always the way to go when it’s an emergency. And we’ve got you covered for those situations.

But starting June 1, 2017, you’ll be responsible for ER costs when it’s NOT an emergency (this isn’t a change to your benefits plan).

http://mediad.publicbroadcasting.net…

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Physicians protest harmful Anthem emergency care coverage policy

By Andis Robeznieks
AMA Wire, August 7, 2017

A new policy by Anthem Blue Cross Blue Shield holds patients responsible for bills stemming from care delivered in emergency departments that is later deemed nonemergent.

The AMA has asked Anthem to immediately rescind the policy in states where it has been put into effect and halt implementation in all other states.

The AMA, the American College of Emergency Physicians (ACEP) and the Medical Association of Georgia (MAG) also suggest that the new policy may violate the “prudent layperson standard” which has been codified into state and federal laws—including the Affordable Care Act (ACA). The standard defines an emergency medical condition as one that manifests itself “by acute symptoms of sufficient severity” that a prudent layperson could reasonably expect that the absence of immediate medical attention could place their health in serious jeopardy. Anthem’s retrospective review appears to be inconsistent with such a standard.

https://wire.ama-assn.org…

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AMA Letter:

From: James L. Madera, MD, EVP and CEO, AMA
To: Joseph R. Swedish, Chairman, President and CEO, Anthem, Inc.

On behalf of the American Medical Association (AMA) and its physician and student members, I write to state our concerns with Anthem’s policy in several states to deny coverage of many emergency services when the diagnosis is retrospectively determined not to have required emergency care. We ask that Anthem rescind this policy in states where it has taken effect, and halt implementation in all other states.

Physicians know that patients and caregivers should never second guess their instincts that emergency care is needed, nor should they be expected to self-diagnose to determine whether, for example, chest pain is a heart attack or indigestion. But with this policy, Anthem is asking that patients act as highly trained diagnosticians, skills our members spent many years of their lives acquiring. Moreover, Anthem’s policy requires that they diagnose their acute symptoms at a critical and emotional moment, when time could be of the essence. The impact of this policy is that very ill and vulnerable patients will not seek needed emergency medical care while, bluntly, their conditions worsen or they die.

http://www.mag.org…

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Comment:

By Don McCanne, M.D.

What a bizarre policy this is. Anthem assigns to the patient the responsibility for deciding if a medical situation is an emergency. Anthem then assumes for itself the responsibility of deciding only after the care has been given whether or not it was an emergency after all, even though the perspective of that judgment can be quite different after a problem is evaluated and managed. If Anthem unilaterally decides, only in retrospect, that the patient’s judgment that this was an emergency was in error, Anthem may refuse to fulfill its obligation to pay for the emergency department services.

Think of various reasons that a decision could be made retrospectively that the visit was not an emergency. Consider those patients who are commonly blamed for wasting health care dollars by abusing the emergency department. Now back up and consider the reasons that the patients thought, before the visits, that they should go to the emergency department. Your ankle was only sprained and not fractured so it could have waited until your physician or nurse practitioner was available on Monday. You are from out of town and you found that your insulin wasn’t packed in your luggage and so your blood sugar is suddenly out of control. You feel very ill and there is an epidemic of a potentially lethal virus but it turns out that you just had a nonlethal respiratory virus, written off as a common cold, even though you really felt sick. You have a seizure disorder and are whisked away to the emergency department while still in a postictal state – the third time this happened. Although it is likely that Anthem would agree to pay for these visits, the threat of nonpayment might keep these people away in situations that might have turned out to be more serious.

Yet you hear all the time about how people are abusing the emergency department. Okay, so you hear about someone who wants a sports physical exam form filled out, but that person doesn’t make it past the triage desk. In my experiences with emergency departments, direct and indirect, I’ve decided that abuses severe enough to penalize a patient financially are so rare that they are basically a fiction that reform opponents keep propagating. Low acuity and low severity might be considered an issue, but that is still relative and not absolute, and the patient should not be penalized for having to make an uninformed decision. People do not go to emergency departments just for social visits.

Based on a “prudent layperson standard” then anyone that clears the triage desk should be assumed to be there legitimately. Under their nonpayment for non-emergency policy, either Anthem would be refusing to pay for legitimate services, or Anthem is making a major PR faux pas by issuing an unnecessary directive that will only make people angry. Either way, this is a terrible policy to establish. But what else do we expect from the private, for-profit insurance industry that places its own net profits over the health care of the patients?

I’ve decided after the fact that getting rid of the private insurers is a true emergency. Let’s do it.

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What’s Next for Progressives?

By Paul Krugman
The New York Times, August 7, 2017

For now, at least, the attempt to repeal the Affordable Care Act appears dead. Sabotage by a spiteful Trump administration is still a risk, but there is — gasp! — a bipartisan push to limit the damage, with Democrats who want to preserve recent gains allying with Republicans who fear that the public will blame them for declining coverage and rising premiums.

This represents a huge victory for progressives, who did a startlingly good job of marshaling facts, mobilizing public opinion, and pressuring politicians to stand their ground. But where do they go from here? If Democrats regain control of Congress and the White House, what will they do with the opportunity?

What would I do instead? I’d enhance the A.C.A., not replace it, although I would strongly support reintroducing some form of public option — a way for people to buy into public insurance — that could eventually lead to single-payer.

Meanwhile, progressives should move beyond health care and focus on other holes in the U.S. safety net.

So if it were up to me, I’d talk about improving the A.C.A., not ripping it up and starting over, while opening up a new progressive front on child care.

I have nothing against single-payer; it’s what I’d support if we were starting fresh. But we aren’t: Getting there from here would be very hard, and might not accomplish much more than a more modest, incremental approach. Even idealists need to set priorities, and Medicare-for-all shouldn’t be at the top of the list.

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NYT Reader Comment:

By Don McCanne, M.D.
San Juan Capistrano, CA

Improving ACA?

None of the incremental proposals would cover everyone.

None of the incremental proposals would remove financial barriers to care.

None of the incremental proposals would return choice of your physicians and hospitals.

None of the incremental proposals would recover the profound administrative waste in our health care financing system.

Single payer?

Everyone is covered for life.

Obtaining care does not create financial hardship.

Patients can choose their health care professionals and institutions.

The efficiency gains would be enough to pay for the gains in coverage.

We need to quit pretending that patching our fragmented, dysfunctional system is almost as good as single payer. It doesn’t come close.

https://www.nytimes.com…

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Comment:

By Don McCanne, M.D.

Perhaps the greatest fraud in health policy today is being perpetrated by the politicians – Republicans who say health care will be more affordable and accessible by taking away coverage, and Democrats who say that incremental additions to the Affordable Care Act are almost as good as enacting single payer – an improved Medicare for all.

We will continue to spend over $3 trillion on health care. That is enough to pay for a system that would be superior to those of all other nations that spend on average half of what we do. Why should we accept less, far less, which is what we would be doing if we merely patched our system – the poorest performing financing system of all wealthy nations?

Once more. Incremental changes to ACA will not fix the fundamental flaws in our financing infrastructure that may leave people sick, broke, and even dead.

We cannot let Paul Krugman rest on his Nobel laureate status as he pontificates for “a more modest, incremental approach,” while acknowledging he would support single payer “if we were starting fresh.” Well, apparently a fresh start is precisely what we need.

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