The Future of Public Health

By Thomas R. Frieden, M.D., M.P.H.
The New England Journal of Medicine, October 29, 2015

The Role of Government

A responsive government can maintain that people are responsible for their own health while also taking public health action that changes default choices to make it easier for people to stay healthy. Key public health actions do one of three things, all of which are now well accepted but were initially controversial. The first is to promote free and open information — such as truth-in-advertising laws and nutrition-facts panels. The second is to protect people from harm caused by others — for example, by detecting adulterated food, prohibiting alcohol-impaired driving, and protecting workers and the public from second-hand smoke. Legal and policy changes in this area often both reflect and accelerate changes in social norms. The third is to implement societal interventions when individuals cannot efficiently or effectively protect their own health through such policies as vaccination mandates, clean air regulations, water fluoridation, micronutrient fortification of food, and elimination of lead in paint and gasoline — interventions that have all greatly improved the health of Americans.

The Future

In the future, clinical medicine could see costs increase without substantial improvement in health outcomes. Alternatively, new delivery models and technology could substantially increase healthy life expectancy. The public health field, for its part, may not be able to keep pace with changing risks and increased opposition to core public health actions that promote healthy living — or it could expand its past successes to further reduce tobacco and alcohol use, control persistent infectious diseases, increase physical activity, improve nutrition, and reduce harms from injuries and other environmental risks.

By working more closely together, clinical medicine and public health can help each other improve health maximally — and emphasize society’s responsibility to promote both healthy environments and consistent, high-quality care. Public health organizations can publicize information on health outcomes and risks that clarifies the need for, or achievement of, substantial progress. Clinical experts can identify and validate preventable harms and effective interventions to protect patients.

The involvement of many parts of society, including government agencies, health organizations, nongovernmental organizations, clinicians, the private sector, and communities, is increasingly important for success. Everyone benefits when people are healthier.

Accountability for outcomes is essential — public health’s obsession with denominators can reduce the number of people missed by interventions that improve health and save lives. Working together, clinical medicine and public health can ensure that people live active and productive lives far longer than was ever thought possible.

(Thomas R. Frieden, MD, MPH, is the Director of the Centers for Disease Control and Prevention [CDC])

http://www.nejm.org/doi/full/10.1056/NEJMsa1511248

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Public Health’s Falling Share of US Health Spending

By David U. Himmelstein, MD, and Steffie Woolhandler, MD, MPH
American Journal of Public Health, November 12, 2015 (online ahead of print)

Abstract

We examined trends in US public health expenditures by analyzing historical and projected National Health Expenditure Accounts data. Per-capita public health spending (inflation-adjusted) rose from $39 in 1960 to $281 in 2008, and has fallen by 9.3% since then. Public health’s share of total health expenditures rose from 1.36% in 1960 to 3.18% in 2002, then fell to 2.65% in 2014; it is projected to fall to 2.40% in 2023. Public health spending has declined, potentially undermining prevention and weakening responses to health inequalities and new health threats.

Discussion

An analysis of the economic and political forces driving public health funding is beyond the scope of this brief report, but it is clear that public health funding has languished over the past decade. It is projected to continue falling as a share of overall health spending, although, like any projection, this should be interpreted cautiously.

The Affordable Care Act originally promised a $15-billion boost in public health funding. However, a 2012 law cut funding for the Affordable Care Act’s Prevention and Public Health Fund by $6.25 billion. Sequestration, which cut federal spending across the board beginning in 2013, reduced it even further; fiscal year 2015 appropriations are less than half the $2 billion originally budgeted.

Meanwhile, many state and local governments — the main source of public health dollars — have faced fiscal challenges. Whereas state medical care spending has continued to increase, public health spending has not.

There is no absolute measure of the optimal level of public health spending. However, an Institute of Medicine panel recently concluded that public health agencies are markedly underfunded, and that US health spending is out of balance, with spending for clinical care disproportionately high compared with spending for “population-based activities that more efficiently and effectively improve the nation’s health.” The current trajectory of health spending seems unlikely to close the funding gap identified by the Institute of Medicine panel.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302908

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Comment:

By Don McCanne, M.D.

A century ago life expectancy was 54. Today it is 79. Public health has played a much greater role in realizing this gain than has clinical medicine. Although most health funds are being directed to clinical services, public health services will need support to continue and to expand the gains that have been more important to society as a whole.

Government must remain responsive to the nation’s health needs. Recognizing that, Congress included in the Affordable Care Act a $15 billion boost in public health funding. However, that was reduced in 2012 legislation by $6.25 billion, and then further reduced by sequestration. Public health appropriations for 2015 are less than half of the $2 billion budgeted.

How can these reductions be justified? The need for austerity? Not based on the billions of dollars being fed into the coffers of the wealthiest amongst us. Less need for government public health services? Not unless we are willing to accept a surge in preventable disease epidemics and injuries from public hazards. Can we justify these reductions based on the ideological principle that the responsibility for health should be shifted from the government to the individual? Even ideologues can suffer or die from uncontrolled epidemics, from uncorrected public hazards, or because of a lack of beneficial interventions that were not implemented.

In addition to these important public health actions, we would also benefit by adopting a government-run health care financing system – a single payer national health program. The failure to act makes our Congress one of the greatest public health hazards that we face. Electing the right people to Congress may be the most important single measure that we could take to maintain and improve the health of our nation.

Many Say High Deductibles Make Their Health Law Insurance All but Useless

By Robert Pear
The New York Times, November 14, 2015

Obama administration officials, urging people to sign up for health insurance under the Affordable Care Act, have trumpeted the low premiums available on the law’s new marketplaces.

But for many consumers, the sticker shock is coming not on the front end, when they purchase the plans, but on the back end when they get sick: sky-high deductibles that are leaving some newly insured feeling nearly as vulnerable as they were before they had coverage.

In many states, more than half the plans offered for sale through HealthCare.gov, the federal online marketplace, have a deductible of $3,000 or more, a New York Times review has found. Those deductibles are causing concern among Democrats — and some Republican detractors of the health law, who once pushed high-deductible health plans in the belief that consumers would be more cost-conscious if they had more of a financial stake or skin in the game.

In Miami, the median deductible, according to HealthCare.gov, is $5,000. (Half of the plans are above the median, and half below it.) In Jackson, Miss., the comparable figure is $5,500. In Chicago, the median deductible is $3,400. In Phoenix, it is $4,000; in Houston and Des Moines, $3,000.

In employer-sponsored health plans, deductibles have also been rising as companies shift costs to workers. Still, the average annual deductible in employer plans, $1,320 for individual coverage according to the Kaiser Family Foundation, is considerably less than the deductibles in many marketplace plans.

Sara Rosenbaum, a professor of health law and policy at George Washington University who supports the health law, said the rising deductibles were part of a trend that she described as the “degradation of health insurance.”

Insurers, she said, “designed plans with a hefty use of deductibles and cost-sharing in order to hold down premiums” for low- and moderate-income consumers shopping in the public marketplaces.

http://www.nytimes.com/2015/11/15/us/politics/many-say-high-deductibles-make-their-health-law-insurance-all-but-useless.html

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Comment:

By Don McCanne, M.D.

The deductibles are out of control. The anecdotes in the full article (link above) demonstrate that many people find that their insurance is “all but useless” simply because they cannot afford to pay the deductibles. Anecdotes do not constitute a scientifically valid study, but they certainly do tell us what is happening to individuals out in the real world.

Insurers needed to keep premiums affordable in order to maintain a viable market of private plans. They do that by shifting costs to patients through ever higher deductibles. This was inevitable through the reform model selected for the misnamed Patent Protection and Affordable Care Act. Because of the large deductibles, actual health care is not affordable for individuals with modest incomes and thus patients do not have the protection that they need.

The three trillion dollars that we are already spending on health care is enough to provide all essential health care services for everyone. With a properly designed financing system there is no need to erect financial barriers to care since cost containment can be achieved through patient-friendly policies such as those of a single payer national health program.

Without proper reform, “degradation of health insurance” will progress. People will face greater financial hardship because of medical bills. People will suffer more because of forgone health care. People will die.

This isn’t right. We need an improved Medicare that includes everyone.

Medicaid coverage improves access to health care and chronic disease control: American Journal of Public Health study

Physicians for a National Health Program, November 12, 2015

Low-income Americans with Medicaid insurance have more awareness and better treatment of chronic diseases, such as high blood pressure, than their uninsured counterparts, a group of Harvard researchers said today. People with Medicaid are also five times more likely to see a doctor than those with no health insurance.

These are among the chief findings of a new study by a team of researchers led by Dr. Andrea Christopher, a fellow at Harvard Medical School, published today in the American Journal of Public Health. The study is based on data gathered from 4,460 poor Americans in national surveys conducted by the Centers for Disease Control and Prevention.

https://www.pnhp.org/news/2015/november/medicaid-coverage-improves-access-to-health-care-and-chronic-disease-control-amer

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Access to Care and Chronic Disease Outcomes Among Medicaid-Insured Persons Versus the Uninsured

By Andrea S. Christopher, MD, Danny McCormick, MD, MPH, Steffie Woolhandler, MD, MPH, David U. Himmelstein, MD, David H. Bor, MD, and Andrew P. Wilper, MD, MPH
American Journal of Public Health, November 12, 2015 (Online ahead of print)

Abstract

Objectives. We sought to determine the association between Medicaid coverage and the receipt of appropriate clinical care.

Methods. Using the 1999 to 2012 National Health and Nutritional Examination Surveys, we identified adults aged 18 to 64 years with incomes below the federal poverty level, and compared outpatient visit frequency, awareness, and control of chronic diseases between the uninsured (n = 2975) and those who had Medicaid (n = 1485).

Results. Respondents with Medicaid were more likely than the uninsured to have at least 1 outpatient physician visit annually, after we controlled for patient characteristics (odds ratio [OR] = 5.0; 95% confidence interval [CI] = 3.8, 6.6). Among poor persons with evidence of hypertension, Medicaid coverage was associated with greater awareness (OR = 1.83; 95% CI = 1.26, 2.66) and control (OR = 1.69; 95% CI = 1.32, 2.27) of their condition. Medicaid coverage was also associated with awareness of being overweight (OR = 1.30; 95% CI = 1.02, 1.67), but not with awareness or control of diabetes or hypercholesterolemia.

Conclusions. Among poor adults nationally, Medicaid coverage appears to facilitate outpatient physician care and to improve blood pressure control.

From the Introduction

The Affordable Care Act (ACA; Pub L No. 111—148) expanded Medicaid insurance for people with low incomes (<138% of the federal poverty level [FPL]) in 31 states. However, whether Medicaid coverage improves health outcomes remains controversial. Several studies described differences in chronic disease prevalence and control between uninsured persons and those with Medicaid, but have not been designed or powered to explore whether Medicaid coverage might cause these differences.

Recently, the Oregon Health Insurance Experiment (OHIE), a randomized, controlled trial, found that Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates. However, the OHIE did not find improvements in other important health outcomes such as control of other chronic diseases, fueling Medicaid’s critics.

The rigorous design of the OHIE provides strong evidence on the impact of Medicaid in the Portland, Oregon, metropolitan area where it was conducted. However, Portland’s relatively robust medical safety net for the uninsured may have attenuated the potential for health improvements from Medicaid expansion compared with other locales, or the United States as a whole.

From the Discussion

Our findings suggest that, nationally, Medicaid was associated with improved access to outpatient medical care, as well as awareness and control of important chronic conditions. Medicaid recipients visited health care providers much more frequently than comparable uninsured individuals, and were more likely to be aware of their hypertension and overweight. In addition, Medicaid recipients were more likely to have their blood pressure controlled, a clinical goal known to reduce all-cause mortality by as much as 17%. However, we found no differences in the diagnosis or control of diabetes, and only nonsignificant differences among those with hypercholesterolemia. We theorize that the lack of findings for diabetes may be because control requires more significant diet and lifestyle changes compared with other chronic conditions, and these changes may not be easily remedied through access to medical care.

Our findings differ from those in the OHIE. First, in the Oregon study, outpatient visits among uninsured individuals averaged 5.5 per year, whereas we found that more than 60% of uninsured individuals nationally had zero or 1 outpatient visit per year. Second, whereas the OHIE observed a 50% increase in outpatient visits among the Medicaid population, we found substantially larger national effects (a 5.0-fold increased odds). Despite methodological differences that preclude exact comparisons with the OHIE data (the NHANES coded outpatient visits into categories), our results suggest that outpatient health care use by the uninsured nationally is probably lower than that of the OHIE’s control population and the boost from Medicaid somewhat bigger. Third, the OHIE found significantly increased detection of diabetes but not hypertension or obesity, and did not show improvement in any physical health measures.

For states that expanded Medicaid under the ACA, enrollment began only 1 year ago; several states are considering expanding Medicaid in the future. Thus, it will likely take several years before nationally representative data become available on the ACA’s impacts. Our data on the association of Medicaid coverage with both outpatient visit frequency and chronic disease care in the pre-ACA era help inform projections of the impact of the largest expansion of Medicaid since its founding.

http://ajph.aphapublications.org/doi/abs/10.2105/AJPH.2015.302925

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Comment:

By Don McCanne, M.D.

Opponents of the Affordable Care Act have been using the Oregon Health Insurance Experiment (OHIE) to supposedly show that Medicaid does not improve health outcomes even though the study was not powered to demonstrate such. Thus this new study is important because it does show that Medicaid improves access, improves awareness of important chronic conditions, and improves control of hypertension. The OHIE trial did show that “Medicaid coverage increased health care use, improved patients’ financial security and self-reported health, lowered depression rates, and raised diabetes diagnosis rates.”

Clearly Medicaid is of benefit. However, as a chronically underfunded welfare program, Medicaid does have significant deficiencies. Last week, a UC Davis study reported that cancer care is worse for Medicaid patients than for other insured patients. The question is, what should we do about it?

Some conservatives would convert Medicaid into a block grant to the states, limiting federal contributions, likely compounding the problem of underfunding. Other conservatives would eliminate Medicaid and place everyone in high-deductible private plans, perhaps with some federal contributions to health savings accounts for low-income individuals. Narrow networks and cost sharing would surely limit access for this population.

A much better solution would be to replace our fragmented health care financing system with a single payer national health program, eliminating cost sharing and network barriers. Since the program would cover all of us, chronic underfunding for a sector of us would not be tolerated.

Support for National Health Insurance Seven Years Into Massachusetts Healthcare Reform: Views of Populations Targeted by the Reform

By Sonali Saluja, Leah Zallman, Rachel Nardin, David Bor, Steffie Woolhandler, David U. Himmelstein, and Danny McCormick
International Journal of Health Services, OnlineFirst – November 3, 2015

Abstract

Before the Affordable Care Act (ACA), many surveys showed majority support for national health insurance (NHI), also known as single payer; however, little is currently known about views of the ACA’s targeted population. Massachusetts residents have had seven years of experience with state health care reform that became the model for the ACA. We surveyed 1,151 adults visiting safety-net emergency departments in Massachusetts in late 2013 on their preference for NHI or the Massachusetts reform and on their experiences with insurance. Most of the patients surveyed were low-income and non-white. The majority of patients (72.0%) preferred NHI to the Massachusetts reform. Support for NHI among those with public insurance, commercial insurance, and no insurance was 68.9%, 70.3%, and 86.3%, respectively (p < .001). Support for NHI was higher among patients dissatisfied with their insurance plan (83.3% vs. 68.9%, p 1⁄4 .014), who delayed medical care (81.2% vs. 69.6%, p<.001) or avoided purchasing medications due to cost (87.3% vs. 71.4%; p1⁄4.01). Majority support for NHI was observed in every demographic subgroup. Given the strong support for NHI among disadvantaged Massachusetts patients seven years after state health reform, a reappraisal of the ACA’s ability to meet the needs of underserved patients is warranted.

From the Methods

The survey included questions about demographics, health status, knowledge about health insurance, and experiences obtaining and using insurance. One question assessed patients’ preferences regarding reform of the health care system. This question, adapted from a prior Washington Post-ABC News poll question, asked patients to choose one of two health care systems: “the current Massachusetts system — which includes a mixture of insurance types, requires that most people pay copays and premiums and mandates that people obtain coverage — or a single national health insurance program — which would be run by the government, paid for by taxes, cover all residents, and not require co-pays or premiums.”

From the Discussion

Our study is the first to directly compare preferences for the MA health reform to NHI. Our findings are not intended to be generalizable to all residents of MA, most of whom are affluent, white, and commercially insured. Our purpose was not to gauge statewide support for NHI, but instead to understand such support in the key policy-relevant populations of patients who were the main target of the health reform — MA residents who are socioeconomically disadvantaged and racial and ethnic minorities.

NHI has been proposed for many years; however, this option is often regarded as unrealistic because it lacks support of key stakeholders, especially the pharmaceutical and insurance industries. Yet, our results suggest a disconnect between the health care financing system that exists in MA (and now nationally) and the system underserved patients prefer.

http://joh.sagepub.com/content/early/2015/10/30/0020731415615314.abstract

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Comment:

By Don McCanne, M.D.

Many polls and surveys have shown that the majority of United States residents would prefer a single payer national health program. This survey is an important addition since it shows that individuals specifically targeted by reform in Massachusetts – individuals who theoretically would be satisfied with the system if reform met their needs – would still prefer to have a single national health insurance program.

Since the reform design of the Affordable Care Act (ACA) was based on the reforms in Massachusetts, it would be safe to say that the response nationally to ACA reforms would be quite similar. So reforms were not adequate for the population they were primarily designed to serve, nor were they adequate for the majority of us who believe that health care should be accessible and affordable for all. ACA falls short of those goals, whereas single payer would meet them. We should go for it.

Obamacare Not as Egalitarian as It Appears

By Tyler Cowen
The New York Times, November 6, 2015

The Affordable Care Act has generated an enormous amount of partisan rancor, but with more access to data, it is worth taking stock of how it has actually been working.

We can safely say that the policy is costing less than anticipated, perhaps 20 percent less, according to a Congressional Budget Office estimate, and that it has reduced the number of Americans without insurance. But the numbers also suggest that by some measures, the Affordable Care Act has had only a limited impact on economic inequality. In fact, I view the policy as an object lesson in the complexity of reducing the harmful consequences of inequality in the United States.

The act has many parts, but let’s focus on the mandate, a core feature that requires those without insurance to buy it. It was intended to help millions of Americans who did not have health care coverage. Under the program, government subsidies are available for the needy, and there is clear evidence that the poorest people, who receive the largest subsidies, are better off under the health reform law.

In that sense, the program has been a success. But whether other individuals subject to the insurance mandate — those who qualify for lower subsidies or for none at all — are also better off is much harder to say, some recent research has found.

Of course, this question may seem simple if you consider health care coverage to be an essential component of a good human life, and perhaps of social justice as well. If you begin with those assumptions, you might conclude that when you require people to buy insurance coverage you are improving their lives — even if they are not willing to pay for the insurance without prompting from the government.

But there is another way of looking at it, one used in traditional economics, which focuses on how much people are willing to pay as an indication of their real preferences. Using this measure, if everyone covered by the insurance mandate were to buy health insurance as the law dictated, more than half of them would be worse off.

This may seem startling. But in an economic study, researchers measured such preferences by looking at data known as market demand curves. Practically speaking, these demand curves implied that individuals would rather take some risk with their health — and spend their money on other things — partly because they knew that even without insurance they still would receive some health care.

One implication is that the preferences of many people subject to the insurance mandate are likely to become more negative in the months ahead. For those without subsidies, federal officials estimate, the cost of insurance policies is likely to increase by an average of another 7.5 percent; even more in states like Oklahoma and Mississippi. The individuals who are likely losers from the mandate have incomes 250 percent or more above the federal poverty level, the paper said. (That figure is $29,425; the federal poverty level is $11,770 for a single person, more for larger families). They are by no means the poorest Americans, but many of them are not wealthy, either. So the Affordable Care Act may not be as egalitarian as it might look initially, once we take this perspective into account.

It is a matter of philosophy whether we should help people even if they may not want to bear the costs, or instead should honor their individual preferences, but either way there is a sustainability problem. Consider that the health law was enacted to replace an unsustainable system in which uninsured people relied on last-ditch emergency room care. Yet enrollment projections suggest that the Affordable Care Act’s insurance mandate may face sustainability issues of its own.

In short, while numerous government programs redistributed income toward the poor successfully in the past, successive improvements, as exemplified by the Affordable Care Act, have become harder to accomplish, as many of the easiest and most efficient opportunities have already been exploited. We have ended up at margins where political divisions and interest group capture make further progress harder to carry out, no matter how good the proposed policies may seem on the drawing board.

(Tyler Cowen is a professor of economics at George Mason University.)

http://www.nytimes.com/2015/11/08/upshot/obamacare-not-as-egalitarian-as-it-appears.html

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Comment:

By Don McCanne, M.D.

Is our health care system under Obamacare (ACA) an egalitarian system? Although ACA includes numerous policies designed to improve health care equity, it still falls far short. Conservative economist Tyler Cowen agrees, although his proposed solutions may be somewhat different from ours.

For a health care system to be egalitarian, it must be equitable. A well designed single payer system would achieve that equity. As an example, the financial burden on middle-income families that Tyler Cowen and many others have described would be lifted.

In the past, Cowen has supported “a Singapore-style system, with single payer on the catastrophic side rather than mandates for private insurance purchase.” Thus he would move us toward a more egalitarian system as well. But the many problems created by moving to the requisite health savings accounts would threaten health care equity, and, thus, threaten egalitarianism itself.

Single payer is the way to go, but let’s make sure that the system design maximizes egalitarianism.

Health at a Glance 2015
OECD Indicators

OECD

This 2015 edition of Health at a Glance – OECD Indicators presents the most recent comparable data on key indicators of health and health systems across the 34 OECD member countries. For a subset of indicators, it also reports data for partner countries.

From the Executive Summary

Health at a Glance 2015 presents cross-country comparisons of the health status of populations and the performance of health systems in OECD countries, candidate countries and key emerging economies.

The key findings of this publication are as follows.

New drugs will push up pharmaceutical spending unless policy adapts

Life expectancy continues to rise, but widespread differences persist across countries and socio-demographic groups

The number of doctors and nurses has never been higher in OECD countries

Out-of-pocket spending remains a barrier to accessing care

Too many lives are still lost because quality of care is not improving fast enough

Health at a Glance 2015 (Read online version – 220 pages):
http://www.keepeek.com/Digital-Asset-Management/oecd/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en

Health at a Glance 2015 (links to PDFs of each section):
http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2015_health_glance-2015-en

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Comment:

By Don McCanne, M.D.

Opponents of health care reform frequently dismiss efforts with the statement that the United States has the best health care system in the world. We don’t. This biennial report of OECD indicators provides international comparisons with tables and graphs that can be very useful in explaining why the United States needs to get serious with our health care reform efforts. It is shameful that we fall far behind our peer nations in so many of the crucial health indicators.

The second link above is particularly helpful since you can readily select international comparisons on whichever topic you want, such as infant mortality, overweight and obesity among children, international migration of nurses, out-of-pocket medical expenditure, and so forth.

Fixing our health care financing system alone will not solve all of our problems, but a single payer system would give us a much better infrastructure on which to function.

Statewide cancer report finds significant disparities in outcomes, quality of care by insurer

UC Davis Health System, November 5, 2015

A new report by the UC Davis Institute for Population Health Improvement (IPHI) comparing quality of care and outcomes for breast, colon, rectal, lung and prostate cancers according to source of health insurance coverage has identified substantial disparities in stage of diagnosis, providers’ use of recommended treatment and survival rates.

According to Kenneth W. Kizer, IPHI and CalCARES director, while cancer treatment has generally improved in recent years, disparities in quality of cancer treatment and survival rates by health insurance remain a significant population health problem.

“Our study found that there are substantial opportunities for improved cancer care among all categories of payers, although the greatest opportunities for improvement exist for patients with Medi-Cal coverage, Medicare/Medi-Cal dual eligibility or no health insurance,” Kizer said. “These patients were diagnosed at more advanced stages of disease, received lower quality of care and had poorer outcomes than persons having private insurance or insurance coverage through Medicare, VA or DoD.

“Given that Medi-Cal is now the largest insurance program in California, with enrollment increasing from 7 to over 12 million members over the past three years and the estimated cost of cancer care for Medi-Cal growing from $3 billion to well over $6 billion, we need to better understand why Medi-Cal patients are not faring better,” he said.

Other key report findings:

* Significantly larger proportions of Medi-Cal and uninsured patients were diagnosed at an advanced stage of disease compared to patients with other sources of health insurance.

* Medi-Cal and uninsured patients had generally less favorable five-year survival rates.

* Medicare/Medi-Cal dual eligible patients were least likely to receive recommended treatment for breast cancer and colon cancer.

* VA patients had the longest intervals between diagnosis and initiation of treatment, but they were generally more likely to receive recommended treatment, and their treatment outcomes compared favorably to patients with other types of health insurance.

* Medi-Cal patients were diagnosed with advanced (stage 4) prostate cancer more than three times as often as patients with private insurance.

http://www.ucdmc.ucdavis.edu/publish/news/newsroom/10522

Full IPHI report:
https://www.ucdmc.ucdavis.edu/iphi/resources/1117737_CancerHI_100615.pdf

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Comment:

By Don McCanne, M.D.

Medi-Cal is a chronically underfunded Medicaid health program for low-income individuals in California. As such, these patients do not receive as much support from the health care community as do otherwise insured patients. This study confirms that cancer patients in the Medi-Cal and in the Medicare/MediCal dual eligible programs have impaired access and impaired outcomes almost comparable to those of uninsured patients.

Of note is that Medicare patients with added Medi-Cal coverage fared worse than did Medicare patients without Medi-Cal coverage. It may be that their lower incomes were associated with other socio-economic problems that result in worse outcomes. It may also be that California has been moving dual eligible patients into Medicaid managed care programs when there is question about how effective these programs are in delivering essential services. Another possibility is that physicians may be rejecting these patients simply because of the welfare stigma of the Medi-Cal program, even though they are on Medicare.

The conservatives have been preaching that Medicaid is as bad as having no insurance at all, and may be even worse. Although their position has been largely refuted, they will surely add this study to their “proof” of this hypothesis. Governors in states that refused to expand their Medicaid programs will find solace in this report.

The solution is obvious. Improve Medicare so that it is a more comprehensive program, and then provide it to everyone. Although other socio-economic factors need to be addressed, at least we would be removing the Medicaid welfare stigma that includes chronic underfunding by our elected representatives.

Marketplace Plans Covering Out-Of-Network Care Harder To Find

By Michelle Andrews
Kaiser Health News, November 6, 2015

Health plans that offer coverage of doctors and hospitals outside the plan’s network are getting harder to find on the insurance marketplaces, according to two analyses published this week.

Two-thirds of the 131 carriers that offered silver-level preferred provider organization plans in 2015 will either drop them entirely or offer fewer of them in January, an analysis by the Robert Wood Johnson Foundation found. Those cutbacks will affect customers in 37 states, according to the foundation.

Preferred provider organization plans, or PPOs, typically offer coverage for doctors and hospitals that aren’t in the plan’s network, but require consumers to pay a larger share of the cost. In contrast, health maintenance organizations, which make up roughly half of the plans offered on the exchanges, generally don’t cover any care provided outside the plan’s network.

Last year, many insurers shrunk the networks of providers in the plans that they sold on the marketplace.

http://khn.org/news/marketplace-plans-covering-out-of-network-care-harder-to-find/

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A Tale Of Two Deliveries, Or An Out-Of-Network Problem

By Erin Taylor and Layla Parast
Health Affairs Blog, November 3, 2015

As co-workers and first-time moms-to-be, we shared much of the pregnancy journey together — including the same employer-sponsored health insurance plan. We even delivered within weeks of each other at the same hospital. For both of us, the key to managing the pain of labor and delivery was the epidural delivered by our anesthesiologists.

When it came to paying the bill, our hospital experiences diverged in one key way. Layla received an unexpected bill for $1,600 for anesthesiology services and warned Erin to expect the same. Yet Erin’s bill never came. Layla happened to deliver on a day when an out-of-network anesthesiologist was on call, while Erin was seen by an in-network anesthesiologist.

Patients who have gone out of their way to ensure they receive care at an in-network facility should not be surprised by bills for involuntary out-of-network services. One solution would be to require that all providers offering care at an in-network facility are included in the plan’s network. Absent that, a few policy changes in the current system could be a step in the right direction.

Make It Transparent

Hospitals could have patients preregister for a planned stay and work with the insurance company to provide each patient with the estimated total expected charges.

The key change here is that the estimated charges would include physician services for in- and out-of-network services. This approach would require the hospital to be straightforward with prospective patients regarding the likelihood of care being provided by out-of-network physicians

Make It Simple

Physician bills and insurance statements need to be simplified.

Clearer explanations of charges, reasons the insurance company did not pay the full amount, and why the patient is being charged would help consumers better understand their bills — and help prepare them to pay them.

Make It Available

Researchers and policymakers have questioned the limited hospital and physician networks in the ACA health insurance marketplaces, as these networks provide access to a smaller set of providers.

Some states, such as Texas, New York, and Louisiana, are tackling out-of-network billing, while legislation was recently introduced in Congress that would place limits on the ability to bill patients for out-of-network services provided at in-network hospitals.

Clearly spelling out expected health care costs, and the likelihood of out-of-network charges, would go a long way toward reducing the economic uncertainty associated with hospital stays — and help patients understand the billing statements they receive after discharge.

Blog Comment by Don McCanne, submitted but not published:

Our particular model of health care financing – a dysfunctional, fragmented, public and private multipayer system – is the most expensive way to finance health care, characterized especially by profound administrative waste. Trying to patch this system only adds further to the administrative complexity – in this case, the effort to create transparency and special handling of out-of-network charges and billing.

Modeling of health care financing systems has shown that the least expensive and most efficient are the national health service and single payer models. Considering our public support of Medicare, the single payer model would be the most feasible for the United States.

With the high numbers of uninsured and under-insured, with the reduced choice of care due to narrow networks, and with the increasing exposure to financial hardship due to shifting of risk to patients, we really do need to abandon the ACA experiment and move forward with a well-designed single payer system.

http://healthaffairs.org/blog/2015/11/03/a-tale-of-two-deliveries-or-an-out-of-network-problem/

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Comment:

By Don McCanne, M.D.

One of the more nefarious methods that private insurers use to reduce their responsibility to pay for health care is to refuse to pay for health care services provided outside of the networks of contracted physicians and hospitals that they, rather than the patient, have selected. They have tightened the screws by shrinking these networks and by dropping some of the PPO plans which permitted at least some out-of-network coverage, but at reduced rates.

As the anecdote presented in the Health Affairs Blog indicates, limited networks can be quite unfair. The two authors of the blog, a policy researcher and a statistician employed by RAND, showed how the same employer-sponsored plan covered obstetrical anesthesia for one but not for the other, simply because by chance one anesthetist was in-network and the other was not.

Recognizing the unfairness of this, the authors recommend some policy changes. They recommend more transparency so you would at least know that the services would not be covered, though it would require more administrative services to obtain and communicate that information. They recommend that bills and insurance statements be “simplified,” though they are actually asking that additional information be required to clarify the network status of each provider involved – more administrative activity. They also suggest that legislation be passed to require special handling of out-of-network charges – yet more administrative complexity.

Unfortunately, this demonstrates the flawed approach to problems with our health care financing system that permeates the health policy community today. They accept as a given our fragmented system of financing health care, as modified by the Affordable Care Act. Their policy approach avoids carefully defining the fundamental problem and moves on with mere patches to our highly dysfunctional system. As this example indicates, the patches typically compound the problems, especially by adding more administrative tasks to our system that is already sinking with administrative overload.

So what is the fundamental problem with narrow networks? It should be obvious. They are designed to benefit the private insurer by shifting more costs to patients who unavoidably or inadvertently obtain care outside of networks. This is not for the benefit of patients; it is detrimental to patient care. Health financing systems should be designed to benefit patients, not multibillion dollar corporations.

So the fundamental problem is the existence of the narrow networks. They need to be eliminated. Along with the narrow networks, all of the other profound administrative excesses that uniquely characterize the American health care financing system need to be eliminated as well. They need to be replaced with an efficient single payer financing system.

Although the Health Affairs Blog posted numerous responses more or less commending the authors for their astute policy recommendations, they did not post my response which happened to be a proposal that would actually prevent the out of network injustices. For that reason, I have included it in today’s message so that it would have at least some limited public exposure. Fortunately, they did post a response by Thomas Cox PhD RN who calls for a single national health insurer.

Physician spending and subsequent risk of malpractice claims: observational study

By Anupam B Jena, Lena Schoemaker, Jay Bhattacharya, Seth A Seabury
BMJ, November 4, 2015

Conclusions

Despite evidence that the majority of US physicians report practicing defensive medicine, no evidence exists on the broader question of whether greater resource use by physicians is associated with fewer malpractice claims. Our findings suggest that greater resource use, whether it reflects defensive medicine or not, is associated with fewer malpractice claims.

Discussion

Despite evidence that many physicians practice defensive medicine to reduce the risk of malpractice claims, no evidence exists on the broader question of whether a greater use of resources by physicians is associated with a reduced risk of such claims. We investigated the association between average resource use by physicians and subsequent malpractice claims. In six of seven specialties, we found that greater resource use was associated with statistically significantly lower subsequent rates of alleged malpractice incidents. For example, internists in the highest fifth of patient risk adjusted resource use were less than half as likely to face a future malpractice claim compared with those in the lowest fifth. Among obstetricians, those with higher caesarean rates — a procedure sometimes considered to be defensively motivated — had lower subsequent rates of alleged malpractice. These relations held even when we adjusted for patient characteristics and accounted for time invariant physician characteristics such as patient mix, clinical skills, or communication skills.

http://www.bmj.com/content/351/bmj.h5516-0.full.pdf+html

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Comment:

By Don McCanne, M.D.

Much has been written about the high costs of defensive medicine – excessive health care services that are delivered merely to protect against the potential of malpractice lawsuits. This study tends to reinforce the belief that there is a solid basis for defensive medicine since higher spending on health care is associated with fewer malpractice claims. But does this additional care represent defensive medicine, or does it represent beneficial health care services that prevent adverse outcomes?

Although physicians admit that they practice defensive medicine, do they really do so strictly because of fear of lawsuits? Or do they do so because there is a real possibility that the patient may experience a significant adverse outcome because of the physician’s failure to detect or manage a serious medical condition? Invariably the latter concern plays at least some role in the medical decisions made.

Imaging is probably the most common procedure that is thought all too often to represent defensive medicine, especially when you consider how many results are normal. But if the physician is 100 percent certain that the imaging procedure will not demonstrate any pathology, then she would not order it since she could not be sued for a condition that does not exist. Imaging is ordered only when there is a real possibility of an abnormal finding, even if the odds are low.

When physicians order low yield tests they often think of them as defensive medicine. But as physicians back off on low yield testing, the incidence of missed pathology increases, as does the risk of a malpractice suit. Thus the test that picks up significant pathology is a beneficial health care service and really should not be categorized as defensive medicine only because it also has that benefit. The same reasoning applies to a test that provides the benefit of reassurance that the potential pathology is not demonstrated.

With concerns about the very high costs of health care, many recommend that we do something to reduce all of this unnecessary defensive medicine. The problem with that is, for the reasons mentioned, not much of health care falls into the category of pure defensive medicine that is of absolutely no clinical value. Therefore there is not much savings to recover. You can talk about flat of the curve medicine or low yield medicine, but as soon as you start eliminating care, you sacrifice the health and well being of a few of your patients, not to mention that you deprive many others of the reassurance they would have from a negative test.

Another point is that so called defensive medicine is a very small percentage of the $3 trillion we are spending on health care, and we can afford that. After all, much of it is still beneficial.

If we really want to reduce waste, we should eliminate the profound administrative excesses of our dysfunctional, fragmented, multi-payer system, by adopting a single payer national health program. We would recover hundreds of billions of dollars that way. That is in contrast to this study that shows that spending more on patients is associated with a lower incidence of lawsuits. Whether we label that defensive medicine or beneficial health care services, we are not going to find much savings there.