Greetings HJM readers – I’m using a different format today.

#1 – Round-up. Plenty of recent news items exemplify the usual rocky functioning of US health care. Here’s a sampling:

Medicaid: Eligibility assessment post-COVID proceeds apace, with 4 million disenrolled so far, widely variable by state (Texas is highest). CMS has asked some states to pause due to problems with the eligibility redetermination. One company is profits very well with this process. Meantime, the DHHS Inspector General found that prior authorization denial rates are especially high in Medicaid, which is 70% under managed care. So, in summary, it’s harder to stay on Medicaid and on Medicaid harder to get care, and private companies profit in the process.

Medicare: Risk selection of healthier individuals (within diagnosis) by Medicare Advantage plans yields 11% lower medical costs than enrollees in traditional fee-for-service Medicare. Higher diagnostic coding intensity adds 6%. The total cost difference of 17% represents $70 billion per year, or $1500 per MA enrollee. Another estimate comes in at 20%. And artificial intelligence (AI) is being misused to arbitrarily limit care. Meantime, drug companies are suing to stop price negotiations in the Inflation Reduction act. Who profits? MA plans and Pharma, of course.

Patients: Administrative barriers to getting care can be very dangerous and extraordinarily expensive. This brings to life the stats — individuals spend 8 hours per month coordinating health care, and one in four insured patients delay or forego care due to administrative hurdles. Medical debt and bankruptcy are pervasive.

Insurers: Profits galore, billions and billions. Definitively covered in Wendell Potter’s HEALTH CARE un-covered. Largely due to Medicare Advantage and Medicaid managed care (see above).

Hospitals: Dubious hospital billing practices are being challenged, as hospital profits grow. Meantime, many rural hospitals suffer existential threats from low private insurer payment rates.

There’s more … there’s always more; our fragmented and dysfunctional insurance approach can be counted on to generate stories of care denied coupled with profits maximized. But enough for today.

#2 – Pause for Reflection

Reading a terrific book, The Persuaders: At the Front Lines of the Fight for Hearts, Minds, and Democracy by Anand Giridharadas. For those committed to progressive policy change, it’s revelatory – laying out vividly what persuasive strategies work. I’m contemplating how the insights can bolster single payer advocacy.

I’m also busy this summer with family travel and cataract / glaucoma surgery (luckily, I have very good insurance, and terrific ophthalmologists).

So, HJM posts will slow.

#3 – Makeover

The HJM website will be reborn later this year in much grander fashion. It will still have all the blog posts, plus some from Don’s prior “quote of the day”, with an advanced search capacity. Plus a glossary and FAQs, as well as visuals and resources for activism. Some short videos too. Stay tuned. If you want to be a “beta tester”, let me know.

Hope you’re having a great summer. – JGK (Dr. Jim Kahn)

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: This week, a profile of challenges facing the UK NHS and an op-ed proposing universal coverage in the US got so many issues right. But they critically missed on pivotal pillars of successful health care financing: adequate funding and comprehensiveness of coverage.

A National Treasure, Tarnished: Can Britain Fix Its Health Service?, New York Times, July 16, 2023, by Mark Landler

As it turns 75 this month, the N.H.S., a proud symbol of Britain’s welfare state, is in the deepest crisis of its history: flooded by aging, enfeebled patients; starved of investment in equipment and facilities; and understaffed by doctors and nurses, many of whom are so burned out that they are either joining strikes or leaving for jobs abroad. …

Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008. Britain spent less a year per person on health care than the wealthiest European Union countries during the decade of austerity, and now has fewer doctors and hospital beds per capita than its European neighbors. Its capital investment lagged the bloc’s average by $41 billion, according to the Health Foundation, which tracks the industry.

We’re Already Paying for Universal Health Care. Why Don’t We Have It?, New York Times, July 18, 2023, by Liran Einav and Amy Finkelstein

There is no shortage of proposals for health insurance reform, and they all miss the point. They invariably focus on the nearly 30 million Americans who lack insurance at any given time. But the coverage for the many more Americans who are fortunate enough to have insurance is deeply flawed.

Health insurance is supposed to provide financial protection against the medical costs of poor health. Yet many insured people still face the risk of enormous medical bills for their “covered” care. A team of researchers estimated that as of mid-2020, collections agencies held $140 billion in unpaid medical bills, reflecting care delivered before the Covid-19 pandemic. To put that number in perspective, that’s more than the amount held by collection agencies for all other consumer debt from nonmedical sources combined. As economists who study health insurance, what we found really shocking was our calculation that three-fifths of that debt was incurred by households with health insurance.

What’s more, in any given month, about 11 percent of Americans younger than 65 are uninsured. But more than twice that number — one in four — will be uninsured for at least some time over a two-year period. Many more face the constant danger of losing their coverage. Perversely, health insurance — the very purpose of which is to provide a measure of stability in an uncertain world — is itself highly uncertain. And while the Affordable Care Act substantially reduced the share of Americans who are uninsured at a given time, we found that it did little to reduce the risk of insurance loss among the currently insured.

It’s tempting to think that incremental reforms could address these problems. For example, extend coverage to those who lack formal insurance. Make sure all insurance plans meet some minimum standards. Change the laws so that people don’t face the risk of losing their health insurance coverage when they get sick, when they get well (yes, that can happen) or when they change jobs, give birth or move.

But those incremental reforms won’t work. Over a half-century of such well-intentioned, piecemeal policies has made clear that continuing this approach represents the triumph of hope over experience, to borrow a description of second marriages commonly attributed to Oscar Wilde. …

Coverage needs to be free at the point of care — no co-pays or deductibles — because leaving patients on the hook for large medical costs is contrary to the purpose of insurance. A natural rejoinder is to go for small co-pays — a $5 co-pay for prescription drugs or $20 for a doctor visit — so that patients make more judicious choices about when to see a health care professional. Economists have preached the virtues of this approach for generations.

But it turns out there’s an important practical wrinkle with asking patients to pay even a very small amount for some of their universally covered care: There will always be people who can’t manage even modest co-pays. …

Finally, coverage must be basic because we are bound by the social contract to provide essential medical care, not a high-end experience. Those who can afford and want to can purchase supplemental coverage in a well-functioning market.

Keeping universal coverage basic will keep the cost to the taxpayer down as well. It’s true that as a share of its economy, the United States spends about twice as much on health care as other high-income countries. But in most other wealthy countries, this care is primarily financed by taxes, whereas only about half of U.S. health care spending is financed by taxes. For those of you following the math, half of twice as much is … well, the same amount of taxpayer-financed spending on health care as a share of the economy. In other words, U.S. taxes are already paying for the cost of universal basic coverage. Americans are just not getting it. They could be.

We … were struck — and humbled — to realize that at a high level, the key elements of our proposal are ones that every high-income country (and all but a few Canadian provinces) has embraced: guaranteed basic coverage and the option for people to purchase upgrades.

Comment:

By Jim Kahn, M.D., M.P.H. and Don McCanne, M.D.

The profile of UK NHS challenges is vivid and compelling in portraying the financial and associated operational and clinical problems plaguing that system. And, buried deep into the article, they do mention, in passing, the reason: “Health care spending rose by an average of less than 2 percent a year from 2010 to 2019, compared with 5.1 percent from 1998 to 2008.”

Let’s be appropriately blunt about this: The Conservative Party (the Tories) are intentionally bleeding the system, since 2010 putting the NHS on austerity footing. See HJM discussion here. Privatization is driving up family financial burdens and increasing mortality.

Thus, the crisis is intentional, policy- and politics-driven. The good news is that there is a good chance that the Tories will pay a steep political price for this evisceration of the popular NHS.

Turning to the US: Wow, Einav and Finkelstein got so much right. The health insurance system is fundamentally broken, unfixable. We need free, universal coverage. Just what we in the single payer movement have been saying for decades. Just what all other wealthy nations do.

But wait, “basic”? What does that mean? The article doesn’t elaborate (their book, to be released later this month, lays out some principles if not a definitive definition …).

We don’t like the sound of it. If “basic” means “access to under-funded and over-stretched providers,” that’s a recipe for a two-tiered system with divergent political interests, like we have for schools. If basic means excluding a subset of medical services, what would we comfortably omit? Not a good solution.

On the other hand, if “basic” means “everything necessary for quality medical care, and no fluff” that could be fine. As long as “medical care” includes inpatient, outpatient, drugs, mental health, dental, vision, medical equipment … everything medically indicated. That’s what other countries do: supplemental insurance is typically just a few percent of total health spending, for example providing access to private hospitals or specialists in a system with excellent public care. Long-term care should be in the “basic” category too.

We think it will be impossible to define “basic” narrowly in a way that is medically sound and doesn’t lead to operational and political fractures. The good news is, we don’t need to be stingy. Analyses of single payer demonstrate that we can provide standardized, comprehensive coverage and still save money for the system and for households.

Our colleague Ed Weisbart put it very well: “Two-tiered systems become as underfunded as the UK’s National Health Service, and outcomes degrade. We’re either all in this together, as a society that looks out for each other, or it’s Game of Thrones for us all.”

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: Current physician payment rules are complex, time-consuming, and unfair to primary care providers. Success of universal coverage with single payer will require a simpler and fairer approach. Fee-for-Time is such a proposal.

Optimizing physician payment for a single-payer healthcare system, International Journal of Social Determinants of Health and Health Services, May 24, 2023, by Stephen B. Kemble and James G. Kahn

For independent physicians, we recommend that a U.S. single-payer system return to fee-for-service payment, replacing RBRVS [Resource-Based Relative Value Scale] with a time- and training-based system designed to be as administratively simple, objective, fair, and incentive-neutral as possible.

This approach would improve on RBRVS in multiple ways. It would base the value of physician services on two straightforward factors: time to complete the procedure (i.e., effort) and years of training (i.e., investment for needed expertise). Physician cognitive and procedural activity would be valued equally, given equal training duration. Practice expenses would be measured and fully covered. Payment would be delinked from extensive documentation, easing EHR demands and ending gaming to maximize income. Physicians would be paid for all time spent on patient care, including documentation, coordination, alternative care delivery modes such as telephonic and telehealth care, and administration. Total physician work and training would determine physician personal income. The physician’s interest in a clinical focus and the system’s interest in efficiency would align to minimize administrative burdens.

A simple example illustrates how this system might work. Assume 2,400 work hours in a year. A doctor who works more hours would earn more, and part-time practitioners would earn less. Practice expenses would be reimbursed at cost, so the work component determines physician personal income. Assume collective negotiations arrive at a base rate for medical school plus internship of $80/hour, plus $25/hour per added year of required training for the next 2 years and $15/hour for subsequent years. That would yield the following personal annual incomes by specialty:

Example Scenario of Fee-for-Time Physician Payment

The complications and gaming now seen with RBRVS-based fee-for-service for providers paired with data demands of capitated fiscal intermediaries, or with capitation of providers, would disappear with the FFT proposal. There would be no disincentive to treat sicker people (no risk pool to game), no risk adjustment of capitation rates and therefore no up-coding, no incentive to deny care inappropriately, no complicated problems with attribution, and no problematic benchmarking methods. In other words, the gaming of payment now seen with all forms of capitation would no longer be motivated or possible.

Conclusion: We believe fee-for-service payment of independent physicians using the Fee-for-Time proposal would be substantially simpler, more objective, fairer, and less costly to administer than fee-for-service based on RBRVS and Evaluation/Management coding or “value-based” payment (notably capitation) with pay-for-performance and risk adjustment. A universal single-payer system that paid hospitals with global budgeting and physicians based on time and expertise, with standardized salaries for employed physicians and time-based payment for independent physicians, would likely achieve greater administrative savings and lower total cost than any proposal based on existing Medicare fee-setting policies or shifting insurance risk onto doctors and hospitals. U.S. healthcare might then achieve cost-effectiveness comparable to all other advanced countries.

Comment:

By Steve Kemble, M.D. and Jim Kahn, M.D., M.P.H.

Moral injury and burnout are now pervasive among U.S. physicians. Doctors are disenchanted with private practice due to the complexities and frustrations of medical billing and collections, compounded by the distractions and documentation demands of “value-based payment.” These administrative tasks frustrate a focus on clinical care. Further, inappropriate interference in physician-patient decision-making by insurance plans is now widespread, via care denials and unreasonable formulary restrictions and prior authorization policies. Physicians are rapidly losing professional autonomy and control over their time.

When private practice becomes untenable, physicians are driven to sell their practices to large corporations, often for-profit and investor-owned, or private equity. They stay on as clinicians, soon discovering that accountability is to shareholders and investors who expect return on investment, even at the expense of the best interests of patients and providers.

For all these reasons a single-payer healthcare system is increasingly attractive to physicians.

However, many remain skeptical because they fear that a publicly funded system would mean “Medicare-as-we-know-it for all,” with complex billing rules including value-based payment. RBRVS has been complex and subject to gaming, detracting from clinical focus. They need assurances about the implications of single payer for medical practice – confidence of adequate income and a focus on clinical care.

Fee-for-Time payment (disclosure: we’re the authors) is a proposed answer to these questions. It greatly simplifies billing, fairly compensates physicians across specialty (notably, including primary care), and leaves providers the latitude to spend adequate time on patient care.

We encourage exploration of FFT, salary, and other simple, fair compensations systems under Medicare for All.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: Dr. Glaucomflecken efficiently & amusingly skewers private equity. Plus a technical report …

How to Ace Your Private Equity Interview, 2-minute YouTube video, by Dr. Glaucomflecken

“Rapid maximal extraction of wealth by any means necessary.”

Comment:

By Jim Kahn, M.D., M.P.H.

Dr. Glaucomflecken, in his usual concise, elegant, and entertaining style, precisely captures how private equity ownership of provider practices threatens physician autonomy, evidence-based medicine, and patient welfare.

For those craving a more technical read today on the rapid expansion of private equity, market distortions, and higher costs, see a detailed report here.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: The White House announced several actions to improve health care financial protections for consumers. Left in place is a fragmented and dysfunctional health insurance system which imposes massive burdens on consumers. Time for single payer!

President Biden Announces New Actions to Lower Health Care Costs and Protect Consumers from Scam Insurance Plans and Junk Fees, The White House, July 7, 2023

• The Biden-Harris Administration is cracking down on junk insurance. New proposed rules would close loopholes that the previous administration took advantage of that allow companies to offer misleading insurance products that can discriminate based on pre-existing conditions and trick consumers into buying products that provide little or no coverage when they need it most. These plans leave families surprised by thousands of dollars in medical expenses when they actually use health care services like a surgery. If finalized, the rule would limit so-called “short-term” plans to truly short time periods, close loopholes made worse by the previous administration, and establish a clear disclosure for consumers of the limits of these plans.

• The Administration is releasing important guidance on rules against surprise medical billing. Biden-Harris Administration rules are already preventing as many as 1 million surprise medical bills every month. New guidance will help stop providers from gaming the system by evading the surprise billing rules with creative contractual loopholes that still leave consumers with unexpected costs.

• The Administration is announcing new steps to protect consumers from unfair medical debt. For the first time in history, the Consumer Financial Protection Bureau, HHS, and Treasury are collaborating to explore whether health care provider and third-party efforts to encourage consumers to sign up for medical credit cards and loans are operating outside of existing consumer protections and breaking the law. Medical credit cards and loans often lead to higher costs without consumers fully understanding the risks.

• The Department of Health and Human Services is releasing a new report showing that nearly 19 million seniors and other Part D beneficiaries are projected to save $400 per year on prescription drugs when President Biden’s $2,000 out-of-pocket cap goes into effect. It’s also releasing state by state data that demonstrates how seniors across the country are helped by just one element of the President’s robust agenda to lower prescription drug prices.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Everyone knows that we have very serious problems with our health care system. We spend the most per capita of any nation, yet leave millions without adequate health care coverage or with any health care coverage at all, resulting in rampant financial hardship and even personal bankruptcy. We know that we can readily fix this by enacting and implementing Medicare for All – a single payer, publicly financed and publicly administered health care financing system.

Yet what reform does the current administration in Washington offer us? They would “crack down” on short-term junk insurance, but nevertheless leave it in place. They would reduce gaming of surprise out-of-network billing, while leaving in place restrictive provider networks and uncovered services. They would rein in abusive medical credit practices, while leaving in place the massive deductibles and cost-sharing (and uninsurance) that result in nearly half of adults having medical debt and hundreds of thousands of bankruptcies annually. They would save Medicare beneficiaries a few hundred dollars in drug costs, while leaving in place lack of and incomplete drug coverage for tens of millions.

It’s time to stop “leaving in place” our fundamental health insurance problems. Medicare for All legislation is sitting in the House and the Senate waiting for action.

My gosh. Talk about insensitivity. Those horrible problems are staring us in the face, and they are merely going to spin their wheels in minor rule-making.

Let’s get real. Single payer! Now!

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: We all spend too much time as patients wrangling medical billing. Here’s one creative approach to accounting for that. Disappears with single payer, of course.

Billing the Hospital Billing Department, The New Yorker, July 3, 2023, by Kendra Allenby

Late-stage capitalism getting you down? Try this fun, D.I.Y. fix—sending your own personalized bill to the hospital billing department:

Dear billing department,

Below are the fees that you’ve incurred. Please pay the balance at your earliest convenience.

Phone calls pre-procedure: To make double, extra sure that the procedure is going to be fully covered by insurance. (Am assured that it will be.) An hour and a half at $300 per hour: $450

Initial phone call post-procedure: Asking why this huge bill showed up after I made double, extra sure that the entire procedure would be covered by insurance. Forty-five minutes at $400 per hour: $300

Follow-up phone call: To find out that the incorrect code was used in billing the procedure. Forty-five minutes at $400 per hour: $300

Misc. phone calls (three): To get the code changed to the correct code. Two hours and fifteen minutes at $400 per hour: $900

One more phone call: To get assurance and e-mail confirmation that the code has been changed and that I will not receive additional bills in the mail. Thirty minutes at $400 per hour: $200

Mug: Smashed when the third bill arrived in the mail. One mug at $47 per mug: $47

Fee for sterile disposal: Of mug. One mug at $347 per mug: $347

Fee for lost sleep: Over the huge bill that should have been entirely covered by insurance. A hundred and thirty-two hours over six months at $300 per hour: $39,600

Therapy to treat anxiety: Resulting from a six-month protracted follow-up on a bill that I never should have received in the first place, plus anxiety spikes upon repeatedly seeing additional bills in the mailbox. Twenty-four sessions at $200 per session: $4800

Tylenol. Couldn’t hurt: One pill at $300 per pill: $300

TOTAL COST: $47,244

My dog has negotiated your rate so that you are only responsible for a percentage of the total cost. If you choose not to go with my dog’s negotiated rate, you may be responsible for the total cost of the fees.

ADJUSTMENTS (as negotiated by dog): -$10,014

CURRENT BALANCE DUE: $37,230

Congratulations, you saved $10,014!

Comment:

By Jim Kahn, M.D., M.P.H.

Exactly right, sadly. Excellent dose of humor for a vexing situation.

We’ve all experienced this (I know I have … e.g., hours of calls regarding vaccination for foreign travel, and many letters and calls and emails to get reimbursed for an urgent care visit, and … and …).

HJM discussed research on this issue in late 2021.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Summary: Democracy and health intersect and interact. Threats to one are threats to both. On this July 4th, let’s recognize these links, and redouble efforts to strengthen democracy by strengthening our health system … with single payer. Health care for all, not for the few who stand to profit the most.

Threats to Democracy Are Threats to Health, MedPage Today, June 29, 2023, by Lawrence O. Gostin and Sarah Wetter

The U.S. is facing dual crises: a crisis of health and a crisis of democracy. Our nation has been getting sicker. We’re facing the greatest decreases in life expectancy in over a century — with causes extending beyond COVID-19 to include rising drug overdoses, injuries, heart and liver diseases, and suicide. Maternal mortality, often considered a test of a society’s commitment to health and equality, has risen sharply. On all of these measures of health and equity, we are falling behind most all of our peer nations.

Our democracy, too, is unwell, with few guardrails on campaign financing, allowing wealthy individual and corporate donors to have outsized influence on policy and gerrymandering, making political representation simply unrepresentative of the populace.

The health of our nation is inextricably linked to the health of our democracy. Our laws directly affect whether someone has access to health services (e.g., abortion or transgender care) and safe environments (e.g., workplace safety or gun control). In theory, democracy is all about the public’s health, safety, and welfare. Political leaders should have no greater calling. Free and fair elections enable voters to elect leaders who fight to fulfill their health needs; political leaders are incentivized to pay attention to voters’ wellbeing, and are held accountable.

Yet, unlimited and dark money has shifted politicians’ attention away from constituents’ health and toward the interests of big donors. Gerrymandering pushes representation toward the extremes, enabling super-majorities in state legislatures that can pass measures harmful to health (e.g., targeting transgender individuals, forgoing Medicaid expansion, banning abortion, encouraging fossil fuels). And voting rights restrictions often fall on the most vulnerable: the poor and racial minorities. When the voting rights of society’s most vulnerable citizens are curtailed, it makes it all too easy for politicians to ignore them.

The Constitution’s Preamble expresses public wellbeing as the quintessential aim of American governance: “We the People, in Order to form a more perfect Union” and to promote the “general Welfare” do “ordain and establish this Constitution.” The “General Welfare” clause expresses a constitutional value of health, peace, and safety. The Supreme Court was supposed to be the guardian of the common welfare. Yet, it has done the opposite. The justices have given rich donors a virtual free hand to give huge sums of money (often dark money); loosened anti-corruptions restrictions; and allowed extreme gerrymandering and voting rights restrictions. …

Medical organizations call voting rights a social determinant of health. The reasons abound: access to voting is consistently associated with better health. Women’s suffrage is associated with decreases in child mortality rates as high as 15%; the Voting Rights Act has been tied to reductions in economic inequality and increased health spending. Voting is linked to reduced risks of cancer death and improved mental health, while voting restrictions correlate with higher likelihood of lacking health insurance.

Comment:

By Jim Kahn, M.D., M.P.H.

On July 4th, we celebrate the founding of US democracy. The revolutionary events of nearly 250 years ago prompted the rise of democracy around the world. This celebration is appropriate, despite – and indeed because of — today’s challenges to democracy at home and abroad. Democracy is under assault, and needs defending.

As Gostin and Wetter persuasively note, the crisis in democracy is echoed by, and intertwined with, a crisis in health. The role of government in advancing the public welfare is undercut by increasing deference to the preferences of corporations and the wealthy. The examples they provide are apt.

But they don’t go far enough. The entire US health system is the antithesis of democracy. A few wealthy individuals and corporations rule the many, by imposing a fragmented insurance system and consolidating the ownership of services. Compromised access to medical care and elevated mortality are accepted as collateral damage from an illusory “free market” in health (which brings no efficiency or welfare maximization) and all-too-real immense financial gains for executives and shareholders. Other wealthy countries democratize health care – everyone has identical coverage, with excellent access to care, and the freedom to choose a provider. Money is saved in the process, and directed to other social needs.

Single payer would foster democracy, freedom, and the general welfare. Let’s issue a “Declaration of Health Care for All”, and revamp our health care into a democracy-conforming and democracy-fostering approach. We will celebrate this revolution for at least the next 250 years.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.