PNHP

Medicare Advantage plans are lying about their networks

Medicare Advantage plans are lying about their networks

The Accuracy of Dermatology Network Physician Directories Posted by Medicare Advantage Health Plans in an Era of Narrow Networks

By Jack S. Resneck Jr, MD; Aaron Quiggle, BA, MS; Michael Liu, BS; David W. Brewster, BA
JAMA Dermatology, October 29, 2014

In the evolving health insurance marketplace, many health plans have increasingly deployed “narrow networks,” reducing the number of contracted physicians or hospitals in a given metropolitan area. Whereas the use of these narrow networks in exchange plans offered under the Affordable Care Act (ACA) might have been expected given pressures to control costs and limit premiums, insurers have taken similar actions in several states to reduce the number of participating physicians in private plans offered as alternatives to Medicare patients known as Medicare Advantage (MA) plans.

Whereas some inaccuracies in ACA exchange plan directories may be expected given the novelty of those products in 2014 and the last-minute contracting that occurred, the MA marketplace is more mature and should have more stable physician listings. Accurate physician lists are particularly important at a time when MA plans are increasingly deploying narrow networks, making determinations of network adequacy critical for both primary care and many difficult-to-access specialties.

Methods 

Using MA enrollment data from July 2014, we determined the 3 largest insurers in each of the 12 MSAs by enrollment.

A scripted telephone call was placed by one of us (A.Q. or M.L.) to each unique physician listing. All calls were placed during varied times of the day and days of the week for each MSA and occurred between August 5 and September 4, 2014.

He asked whether the listed physician accepts the relevant MA plan(s) and sees patients with itchy rashes and, if so, when the next available new-patient appointment was.

Results

For the largest MA plans in the 12 MSAs… there were 4754 physician listings (4408 MDs, 346 DOs) meeting inclusion criteria.

Within health plans, a large number of these listings represented duplicates (2164 [45.5%]).

Among the 2590 remaining unique listings, there were many that our callers were unable to contact (464 [17.9% of unique listings]). Some of these were nonworking or wrong telephone numbers, and others were offices that reported that they had never heard of the listed physician. Several more (221 [8.5% of unique listings]) reported that the listed physician had died, retired, or moved out of the geographic area.

Many of the listed physicians whose offices we reached were not accepting new patients (221 [8.5% of unique listings]). There were also several who were subspecialized and were not willing to make an appointment for a patient with an itchy rash.

Fewer than half of listed physicians for each plan (1266 [48.9% of unique listings]) were reached, accepted the listed plan, and offered an appointment for a patient with an itchy rash. Because of the large number of duplicate listings, this translates to only 26.6% of individual directory listings being unique, taking the listed plan, and offering a medical dermatology appointment.

Wait times for the appointments offered by those listed physicians were relatively long (median, 30 days; mean, 45.5 days).

Discussion

Our findings of inaccurate physician directories and long dermatology appointment wait times in many areas come at a time when many health plans are narrowing their MA networks by reducing the number of in-network physicians. There has been concern voiced about the proprietary methods that health plans are using to select physicians for termination and whether those methods themselves may limit access for patients with more costly health conditions. Our study cannot address those specific concerns, but our data do support the hypothesis that the large physician directories posted by many health plans exaggerate perceived access to dermatologists for MA patients. Furthermore, the long in-network appointment wait times observed for many of these plans suggest a lack of capacity that can only be exacerbated by further network narrowing.

http://archderm.jamanetwork.com/article.aspx?articleid=1919439

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Comment:

By Don McCanne, MD

One of the more alarming trends in health insurance innovation is the increasing use of narrower provider networks. Patients are losing their choice of their health care professionals and hospitals. Not only can this result in impaired access and longer wait times, it also can unfairly benefit the insurers by discouraging sicker patients from enrolling because of concerns about being unable to access the care that they need – especially specialized services.

This study looked at provider lists of dermatologists offered by a representative group of major private Medicare Advantage plans. Although the plans offered in the new insurance exchanges under the Affordable Care Act can plead being victims of transitional logistical complexities causing errors in their network lists, the private Medicare Advantage plans have been around for many years in an expansionary market and thus should represent the best of network administration. So how are they doing?

This study was completed less than two months ago and thus represents the current state of the art. When contacted, only one-fourth (26.6%) of the total number of dermatologists listed in the Medicare Advantage provider networks offered new appointments, and the mean wait time was 45 days. Only one-fourth! And with a 45 day wait!

This narrow network thing has really caught on. Some of these same Medicare Advantage plans are now cutting more providers from their networks, including dermatologists. And the newer ACA exchange plans are starting out with even narrower networks.

How can this benefit patients? Take away choice? Hiding true providers in otherwise worthless lists? Moving patients further back in the queues? And they want to give us more of this?

Traditional Medicare doesn’t have any networks. They are a creation of the private insurance industry, designed to serve their own nefarious interests. Enough! Time to get rid of them and enact an improved Medicare that takes care of all of us.

One way Medicare Advantage plans game risk scores

Another whistleblower suit alleges Medicare Advantage fraud

By Fred Schulte
The Center for Public Integrity, October 29, 2014

A new whistleblower lawsuit accuses a California health care firm of diagnosing “false and fraudulent” medical conditions that several Medicare Advantage plans allegedly used to overcharge the federal government by $1 billion or more.

The suit was filed by Anita Silingo, a former compliance officer for Mobile Medical Examination Services, Inc., or MedXM. The Santa Ana, California-based firm sends medical professionals to the homes of Medicare Advantage members to assess their health.

The suit also names four Medicare Advantage insurance plans which, Silingo alleges, “turned a blind eye” to the practices. The health plans named in the suit are: Molina Healthcare of California; WellPoint, Inc., which operates  Anthem Blue Cross and Blue Shield; Health Net of California, Inc. and Alameda Alliance for Health.  None would comment.

MedXM chief executive officer Sy Zahedi called the allegations “categorically not true.”

Critics argue that federal officials waste billions of tax dollars every year by failing to crack down on health plans that game the arcane payment system.  At least five other whistleblower cases accusing Medicare Advantage of fraudulently inflating risk scores are winding through federal courts, records show.

The four health plans “turned a blind eye to the truth” because the MedXM health assessments made them money, according to the suit. Medicare Advantage plans argue that the in-home health assessments can help members stay fit and in their homes as long as possible by spotting untreated diseases and dangerous living conditions. While the doctors and nurses don’t offer any treatment during their visit, they report their exam findings to the patient’s primary care physician.

But home visits also are controversial, largely due to their impact on Medicare costs.

The lawsuit names nearly 70 nurse practitioners and physician assistants whom she claims were not properly supervised by doctors. Some evaluations were conducted over the phone rather than in person, as required by federal regulations. In other cases, Silingo alleged, medical coders directed the health professionals to “modify” medical records “in order to increase the severity of the patients’ diagnosis.”

Some doctors and nurses were scheduling 20 to 25 of the home visits per day. The suit names three doctors whom it says scheduled at least 20 of the visits in a single day.

In December of 2012 about 750 Molina patients had “identical vital statistics for age, weight, sex height, blood pressure and heart rate” as well as similar medical findings, all done by the same doctor.

That doctor was “routinely” completing more than 22-25 assessments per day “traveling over a wide geographic area making it implausible that he actually performed the work that he claimed,” according to the suit.

Another whistleblower suit alleges Medicare Advantage fraud

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Comment:

By Don McCanne, MD

Assuming the allegations of this lawsuit prove to be true, it appears that private Medicare Advantage insurers contracted with a private company that hired health care professionals to do in-home health assessments, not for treatment purposes but merely to collect data that, combined with innovative coding, could be used to increase government payments based on inflated risk scores.

These questionable visits were not only useful for increasing profits, they also served as a marketing tool in which the plans could claim that they were providing “coordinated care” not available in the traditional Medicare program, even if these visits were not much more than a sham.

It was already known that private Medicare Advantage insurers were gaming risk scores to increase profits. The revelation in this lawsuit demonstrates one of the mechanisms apparently used to cheat the Medicare program.

Medicare Advantage plans are paid more yet take away choice by limiting care to provider networks. So why do people enroll in them? It is primarily because of the lower cost sharing of the plans that have premiums that are much lower than the Medigap plans, which also offer similar cost sharing reductions. To reduce out-of-pocket spending, Medicare Advantage plans take away choice and Medigap plans charge excessive premiums.

If the same out-of-pocket cost reductions were rolled into the traditional Medicare program then patients could receive the same level of benefits as in Medigap or Medicare Advantage, while preserving free choice of hospitals and health care professionals. Even better, if the other flaws in Medicare were also fixed then we could use it for health care coverage for everyone – an improved Medicare for all.

Vermont faces rough road to single payer

Correction: State No Longer Looking to Administer Medicare

By Anne Galloway
VTDigger, October 26, 2014

Two recent stories about the relationship between Medicare and Green Mountain Care, the state’s planned universal publicly financed health care program – often called single-payer – were inaccurate. The stories were based on statutes on the Legislature’s website that had not been updated.

Section (e) of chapter 18, Public Private Universal Health Care System, in Title 33, Human Services, still states online that, “The Agency shall seek permission from the Centers for Medicare and Medicaid Services to be the administrator for the Medicare program in Vermont. If the Agency is unsuccessful in obtaining such permission, Green Mountain Care shall be the secondary payer with respect to any health service that may be covered in whole or in part by Title XVIII of the Social Security Act (Medicare).”

Act 144, which was enacted in 2014, repeals that section, though the statutes have not been updated online.

Section (f) of the same chapter now reads, “Green Mountain Care shall be the payer of last resort with respect to any health service that may be covered in whole or in part by any other health benefit plan, including Medicare, private health insurance, retiree health benefits, or federal health benefit plans offered by the military, or to federal employees.”

State officials have said they are no longer seeking to administer Medicare as part of Green Mountain Care, and the law reflects that change.

It is currently unknown what Green Mountain Care will cover or what private supplemental health insurance policies will be offered once the program is in place.

Gov. Peter Shumlin has said there is no reason to expect that currently available supplemental coverage options for Medicare would change if the state moves forward with a single-payer health care system.

Correction: State no longer looking to administer Medicare

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Vermont Act 144

An act relating to miscellaneous amendments to health care laws.

Sec. 1  Principles for Health Care Financing

  (3)  As provided in 33 V.S.A. § 1827, Green Mountain Care shall be the payer of last resort for Vermont residents who continue to receive health care through plans provided by an employer, by another state, by a foreign government, or as a retirement benefit.

Sec. 2 Vermont Health Benefit Exchange

  (4)  To the extent permitted by the U.S. Department of Health and Human Services, the Vermont Health Benefit Exchange shall permit qualified employers to purchase qualified health benefit plans through the Exchange website, through navigators, by telephone, or directly from a health insurer under contract with the Vermont Health Benefit Exchange.

Sec. 6  Administration; Enrollment

  (e) [Repealed.]

  (f) Green Mountain Care shall be the payer of last resort with respect to any health service that may be covered in whole or in part by any other health benefit plan, including Medicare, private health insurance, retiree health benefits, or federal health benefit plans offered by the military, or to federal employees.

Governor signed bill: May 27, 2014: http://www.leg.state.vt.us/docs/2014/Bills/H-0596/ACT0144%20As%20Enacted.pdf

Green Mountain Care: http://www.greenmountaincare.org/vermont-health-insurance-plans

Vermont Health Connect: http://info.healthconnect.vermont.gov/healthplans

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Shumlin Won’t Pursue Single Payer If It Doesn’t Help Economy

By Bob Kinzel
VPR, September 12, 2014

Act 48, the law that put Vermont on the path to a single-payer health care system, was passed in 2011. It called on the governor to unveil a single-payer financing plan in January of 2013.

That didn’t happen because Shumlin said he needed more time to develop a plan. Shumlin said he would be ready to release his proposal in January of this year.

But Shumlin missed this deadline as well. He now says he’ll unveil his plan at the start of the Legislative session in January.

Shumlin says there’s no point pursing a single-payer option if the effort will hurt the state’s business community.

“If we come up with a financing plan that doesn’t grow jobs, economic opportunity, and make Vermont more prosperous, trust me, we’re not going to do it,” said Shumlin.

http://digital.vpr.net/post/shumlin-wont-pursue-single-payer-if-it-doesnt-help-economy

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Comment:

By Don McCanne, MD

Many consider Vermont to be the trailblazer for a state single payer program, serving as a model for other states to enact single payer reform. Vermont does have lessons for the rest of us. Let’s see what they are so far.

Green Mountain Care is Vermont’s program for Medicaid and for Dr. Dynasaur (Vermont’s Medicaid program for children and pregnant women). Most participants are now required to enroll in PC Plus – a Medicaid primary care managed care program. Vermont Health Connect is Vermont’s health insurance exchange (marketplace) under the Affordable Care Act through which individuals and small businesses can purchase insurance.  Many Vermonters still have access to other programs such as Medicare, employer-sponsored health plans, retiree plans, and federal employee programs such as FEHBP and Tricare. So far this is not really much different than programs in other states – certainly far from single payer.

What about Medicare? Vermont has given up on attempting to become the administrator of Medicare, much less rolling Medicare funds into a universal single payer program. Gov. Peter Shumlin has even stated that “there is no reason to expect that currently available supplemental coverage options for Medicare would change.” Thus apparently they are continuing even the private Medigap supplements and private Medicare Advantage plans.

What about Green Mountain Care – the Medicaid program that was to be the single payer for Vermont? A few months ago legislation was signed by Gov. Shumlin that stated, “Green Mountain Care shall be the payer of last resort with respect to any health service that may be covered in whole or in part by any other health benefit plan, including Medicare, private health insurance, retiree health benefits, or federal health benefit plans offered by the military, or to federal employees.” Further, “Green Mountain Care shall be the payer of last resort for Vermont residents who continue to receive health care through plans provided by an employer, by another state, by a foreign government, or as a retirement benefit.” At this point in time, that does not look like a program that is being remodeled to fulfill the role of a single payer.

The original Vermont legislation called on Gov. Shumlin to unveil a single payer financing plan in January, 2013. He missed that deadline and again missed the next one in January, 2014. He now says that he intends to release a plan in three months. We will have to wait to see what that proposal is, but at this late stage he is saying, “trust me, we’re not going to do it,” if the effort will hurt the business community. That seems quite tenuous for having worked on it a couple of years.

Many still talk about the enabling ACA waiver that Vermont will obtain in 2017, but the ACA section 1332 waiver applies only to the subsidies and some specific requirements of ACA. Even combined with Sec. 1115 Medicaid waivers and waivers for Medicare demonstration programs, especially considering the ERISA barriers, we simply do not have enough leeway for states to independently establish their own bona fide single payer systems.

The point is that we must have comprehensive federal legislation if we wish to establish state-level single payer systems. We need need the federal funds currently used in other federal health programs such as Medicare and Medicaid, and we need relief from federal statues and regulations such as ERISA. It would be far better to simply enact a national single payer program, but those who wish to pursue a state model must still advocate for comprehensive federal legislation.

Regardless, we can have single payer if we all work together to create the momentum for federal legislation, state and/or national, but none of us will see single payer if we each confine our activities to our respective states. Many have called for a cooperative effort. This is it!

EHRs add to paperwork burden for US physicians, study finds

By Emily Rappleye
Becker’s Hospital Review, Oct. 27, 2014

EHRs increase time spent on non-patient-related paperwork, a burden that consumes 16.6 percent of the average American physician’s working hours, according to a study published last week in the International Journal of Health Services.

The nationwide study was conducted by two New York City internists, Steffie Woolhandler, MD, and David Himmelstein, MD, who co-founded Physicians for a National Health Program and both serve as professors of public health at the City University of New York and lecturers in medicine at Harvard Medical School. Their findings are based on confidential data from the 2008 Health Tracking Physician Survey.

The average physician clocks 8.7 hours of administrative work, which includes billing, insurance approval procurement, financial and personnel management and contract negotiation, according to the study.

“American doctors are drowning in paperwork,” Dr. Woolhandler said in a statement.

Based on the study, EHRs are not reducing the load. Physicians using a combination of electronic and paper records spent 18 percent of their time on administrative paperwork, while those using EHRs alone spent 17.2 percent of their time on such tasks. However, physicians using entirely paper records only spent 15.5 percent on bureaucratic tasks.

The authors also found small group practices are more efficient with paperwork than both solo practices and large group practices of 100 or more physicians. Small groups used only 16.3 percent of their time on administrative work, as compared to 19.7 percent in larger groups.

While the paperwork piles up for some, the average physician isn’t too overburdened. Physicians clocking up to 20.6 percent of their time on administration were “very unsatisfied,” but those close to the national average, who spent 16.1 percent of their time on such work, rated themselves as “very satisfied,” according to the study.

http://www.beckershospitalreview.com/hospital-physician-relationships/ehrs-add-to-paperwork-burden-for-us-physicians-study-finds.html

Activists Rally for Universal Healthcare

By Daphne C. Thompson
The Harvard Crimson, Oct. 27, 2014

Holding signs reading “Healthcare not warfare” and “Insurers deny, people die,” more than 100 activists rallied at Boston Common Sunday to promote a single-payer healthcare system and an emergency global health fund.

The participants—including a Harvard contingent of around a dozen students and affiliates—marched the perimeter of the Common before arriving at the Parkman Bandstand, where they listened to several speakers describe the scale and severity of the global health crisis, in part due to the inequity of treatment.

Donald M. Berwick ’68, a health care policy lecturer at the Medical School who unsuccesfully ran for his party’s nomination in the ongoing Massachusetts gubernatorial race, compared the magnitude of the health care campaign to the feminist and civil rights movements.

“A fight for a rational, humane, universal, sensible health care system which makes health care a human right—not just here, but anywhere—is a fight of that dimension,” he said. “We need to engage it.”

The Boston Rally for the Right to Health was one of many similar events taking place in 63 countries this weekend as part of the Article 25 “Global Day of Action” campaign, named for the section in the United Nation’s Universal Declaration of Human Rights that declares health as an inalienable right.

The activists gathered signatures to petition gubernatorial candidates Martha Coakley and Charles D. Baker ’79 to support a state-run, single-payer healthcare system in Massachusetts. A single-payer system would provide all citizens with comprehensive health care under a single, publicly-financed insurance plan.

“As cynical as it is, a lot of times it takes generational change for these kinds of ideas to become more ingrained,” said Frances Ding ’17, a member of Harvard Partners in Health, who attended the rally. “More and more people are looking to other countries and thinking, ‘why are they significantly happier with their health insurance?’ while we still can’t ensure health insurance for millions of Americans.”

Brook K. Baker, a law professor at Northeastern University who spoke at the rally, said that single-payer health care represents a more cost-efficient and equitable alternative to the current market-run system. Citing discriminatory insurance policies and pharmaceutical interests as tantamount to health rationing, he urged the protesters to pressure their representatives to invest in universal care.

On a global scale, the protesters advocated for a $20 billion Global Health Emergency Fund to combat epidemics like Ebola and strengthen medical systems in every nation.

“If those countries had access to healthcare to begin with, we wouldn’t be seeing this massive epidemic,” said Joia Mukherjee, an associate professor at Harvard Medical School who spoke on the Ebola crisis. “There is not healthcare anywhere until there’s healthcare everywhere.”

Daphne C. Thompson is a contributing writer.

http://www.thecrimson.com/article/2014/10/27/boston-activists-rally-healthcare/

Female workforce pays more for health benefits

Section 1557 of the Patient Protection and Affordable Care Act

U.S. Department of Health and Human Services

Section 1557 is the civil rights provision of the Affordable Care Act.  Section 1557 prohibits discrimination on the ground of race, color, national origin, sex, age, or disability under “any health program or activity, any part of which is receiving Federal financial assistance … or under any program or activity that is administered by an Executive agency or any entity established under [Title I of ACA]….”   Section 1557 is the first Federal civil rights law to prohibit sex discrimination in health care.  To ensure equal access to health care, Section 1557 also applies civil rights protections to the newly created Health Insurance Marketplaces established under the Affordable Care Act.

http://www.hhs.gov/ocr/civilrights/understanding/section1557/

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Behind in Pay, Behind in Benefits

By Beth Umland
Mercer, October 17, 2014

It’s well known that working women earn less money than their male counterparts, but they may also be at a disadvantage when it comes to health benefits. Using data from Mercer’s National Survey of Employer-Sponsored Health Plans, we compared companies with workforces that are 65% female or more to those with workforces that are 65% male or more. About half of the mostly female companies are in health care and about a quarter are in the services sector, while mostly male companies are found predominately in manufacturing. The percentage of employees in collective bargaining agreements is about the same for the two groups, at just under 15%. Not surprisingly, when the workforce is mostly female, the average salary is about $10,000 less than when the workforce is mostly male.

Pay and benefits tend to go hand in hand. The health benefits at organizations with predominantly female workforces are also less generous than in those with predominantly male workforces. Because women generally use health services more than men, the disparity in benefit levels has an even greater financial impact. Women use maternity services, and childbirth, the leading cause of hospitalization in the US, accounts for a quarter of all hospital stays. We found that average employee contributions as a monthly dollar amount are higher in mostly female companies: For coverage in a PPO, the most common type of medical plan, the monthly contribution for family coverage is 31% higher. In addition, average in-network and out-of-network deductibles and out-of-pocket maximums are consistently higher. For example, the average in-network PPO deductibles in mostly female companies are $727 and $1,614, respectively, for individual and family coverage, compared to $557 and $1,318 at mostly male companies.

And the benefit gap doesn’t end with active employment. Mostly male companies are also more likely to offer retiree medical benefits – 27% offer medical coverage to pre-Medicare-eligible retirees, compared to just 19% of the mostly female companies.

Currently, about a third (36%) of companies with mostly female workforces do not provide coverage to all employees working an average of 30 or more hours per week. They will be required to do so in 2015.

http://ushealthnews.mercer.com/article/252/behind-in-pay-behind-in-benefits

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Comment:

By Don McCanne, MD

It’s shameful. Although the Affordable Care Act (ACA) specifically prohibits discrimination based on sex, employers are still able to provide plans that are based on the underwriting characteristics of their employees. This Mercer report compares workforces that are over 65% female with those over 65% male and shows that females receive less generous health benefits – paying 31% more for deductibles and 31% more for the premium contribution for family coverage.

This is a direct result of the fact that ACA was designed to perpetuate employer-sponsored health plans. Had Congress enacted a single payer national health program instead, not only would sex-based underwriting have been eliminated, the financing of the entire health care system would have been changed to an equitable system based strictly on ability to pay.

Female workforces are paid about $10,000 less than male workforces. Under single payer, their share of health care financing would have been less than for males, since income taxes are progressive. For men who might think it is unfair that women should pay less in health care taxes, they could help fix that by supporting pay equity.

Improving trust in the profession

Public Trust in Physicians — U.S. Medicine in International Perspective

By Robert J. Blendon, Sc.D., John M. Benson, M.A., and Joachim O. Hero, M.P.H.
The New England Journal of Medicine, October 23, 2014

One emerging question is what role the medical profession and its leaders will play in shaping future national health care policies that affect decision making about patient care.

Research suggests that for physicians to play a substantial role in such decision making, there has to be a relatively high level of public trust in the profession’s views and leadership. But an examination of U.S. public-opinion data over time and of recent comparative data on public trust in physicians as a group in 29 industrialized countries raises a note of caution about physicians’ potential role and influence with the U.S. public.

In a project supported by the Robert Wood Johnson Foundation and the National Institute of Mental Health, we reviewed historical polling data on public trust in U.S. physicians and medical leaders from 1966 through 2014, as well as a 29-country survey conducted from March 2011 through April 2013 as part of the International Social Survey Programme (ISSP), a cross-national collaboration among universities and independent research institutions.

In 1966, nearly three fourths (73%) of Americans said they had great confidence in the leaders of the medical profession. In 2012, only 34% expressed this view. But simultaneously, trust in physicians’ integrity has remained high. More than two thirds of the public (69%) rate the honesty and ethical standards of physicians as a group as “very high” or “high” (Gallup 2013).

Today, public confidence in the U.S. health care system is low, with only 23% expressing a great deal or quite a lot of confidence in the system. We believe that the medical profession and its leaders are seen as a contributing factor.

This phenomenon does not affect physicians in many other countries. Indeed, the level of public trust in physicians as a group in the United States ranks near the bottom of trust levels in the 29 industrialized countries surveyed by the ISSP. Yet closer examination of these comparisons reveals findings similar to those of previous U.S. surveys: individual patients’ satisfaction with the medical care they received during their most recent physician visit does not reflect the decline in overall trust. Rather, the United States ranks high on this measure of satisfaction. Indeed, the United States is unique among the surveyed countries in that it ranks near the bottom in the public’s trust in the country’s physicians but near the top in patients’ satisfaction with their own medical treatment.

Part of the difference may be related to the lack of a universal health care system in the United States. However, the countries near the top of the international trust rankings and those near the bottom have varied coverage systems, so the absence of a universal system seems unlikely to be the dominant factor.

The United States also differs from most other countries in that U.S. adults from low-income families (defined as families with incomes in the lowest third in each country, which meant having an annual income of less than $30,000 in the United States) are significantly less trusting of physicians and less satisfied with their own medical care than adults not from low-income families.

In drawing lessons from these international comparisons, it’s important to recognize that the structures in which physicians can influence health policy vary among countries. We believe that the U.S. political process, with its extensive media coverage, tends to make physician advocacy seem more contentious than it seems in many other countries. Moreover, the U.S. medical profession, unlike many of its counterparts, does not share in the management of the health system with government officials but instead must exert its influence from outside government through various private medical organizations. Moreover, in terms of health policy recommendations, the U.S. medical profession is split among multiple specialty organizations, which may endorse competing policies.

Nevertheless, because the United States is such an outlier, with high patient satisfaction and low overall trust, we believe that the American public’s trust in physicians as a group can be increased if the medical profession and its leaders deliberately take visible stands favoring policies that would improve the nation’s health and health care, even if doing so might be disadvantageous to some physicians. In particular, polls show that Americans see high costs as the most important problem with the U.S. health care system, and nearly two thirds of the public (65%) believes these costs are a very serious problem for the country. To regain public trust, we believe that physician groups will have to take firm positions on the best way to solve this problem. In addition, to improve trust among low-income Americans, physician leaders could become more visibly associated with efforts to improve the health and financial and care arrangements for low-income people. If the medical profession and its leaders cannot raise the level of public trust, they’re likely to find that many policy decisions affecting patient care will be made by others, without consideration of their perspective.

http://www.nejm.org/doi/full/10.1056/NEJMp1407373

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Comment:

By Don McCanne, MD

Another unique feature of the U.S. health care system that sets us apart from other nations: “You just can’t trust doctors nowadays, but my doctor is really good.” What can we make of this?

In general, individuals are relatively satisfied with their personal care. Low-income individuals are less satisfied, but that is likely related to the deficient financing of their care and the consequences of that – a characteristic of our fragmented, dysfunctional system of financing health care. But, overall, our system is capable of ensuring patient contentment.

It is the confidence in physician leadership that has deteriorated. The authors of this article suggest some possible explanations, but it is more likely that the image of the profession at large has changed from that of the dedicated personal physician steeped in the Hippocratic tradition, to that of the high-tech, entrepreneurial agent of the medical-industrial complex. Combine that perspective with the very high costs of health care today – costly care which physicians orchestrate – and it is no wonder that the public is no longer as trusting of the profession. Only “my doctor” is immune to this.

When you look at the role that the AMA had in the enactment of the Affordable Care Act, it is evident that they were not there to represent patients; they were there alongside the other elements of the medical-industrial complex – especially the insurance, pharmaceutical and hospital industries – to be sure that they got their own share of the action. The only patient advocates present were the consumer organizations that chose the default option of “political feasibility,” becoming “strange bedfellows” of the private insurance industry.

There are many dedicated individual physicians and other health care professionals who clearly place patients first. They are well represented in organizations such as Physicians for a National Health Program. They are also well represented in the AMA and the various specialty organizations, but, as a collective voice, they are ineffective in communicating the tradition of caring; rather they passively communicate the acceptance of the medical-industrial complex – a very sterile advocacy position.

Let’s indulge in a fantasy. Let’s imagine that our professional organizations all joined together in a clarion call for comprehensive, affordable, high-quality care for absolutely everyone – including those low-income individuals who distrust the profession today. Single payer would bring us such quality that is truly affordable.

With a voice unified in support of the patient, what do you think would then happen to the level of confidence that the public has in the medical profession? Physicians would once again relish respect as a noble profession advocating for their patients.  As an aside, it would also mean that they would have a very pleasant work environment and be adequately compensated for their efforts. If the system works for patients, it will work for physicians.

Physicians Frustrated By Administrative Burdens of Medical Practice

By Marie Benz, M.D.
MedicalResearch.com, Oct. 23, 2014

Interview with Steffie Woolhandler, M.D., M.P.H., Professor of Public Health and City University of New York, Lecturer (formerly Professor of Medicine) at Harvard Medical School, Primary Care Physician Practicing in the South Bronx.

Medical Research: What is the background for this study?

Dr. Woolhandler: Physicians like myself are extremely frustrated by the administrative burdens of medical practice. Many hours of physicians’ time each week go to administrative work completely unrelated to good patient care, but mandated by private insurers and other payers. Colleagues often tell me that they love seeing patients but are getting burned out by the paperwork.

Medical Research: What are the main findings?

Dr. Woolhandler: We found that the average practicing U.S. physician spends 8.7 hours per week, 16.6 percent of his or her working hours, on non-patient related paperwork. (This figure excludes time spent writing progress notes, communicating with other doctors, or ordering tests, which we considered patient-related work. However, it includes billing, obtaining insurance referrals, financial and personnel management, and contract negotiations). Pediatricians spent the least time of any specialty on paperwork (14.1 percent of their work week) and psychiatrist the most (20.3 percent). Spending more time on paperwork significantly reduced physicians’ career satisfaction. Overall, U.S. physicians spent 168.4 million hours on paperwork in 2008, at an opportunity cost of $102 billion in lost patient-care time.

Unfortunately, many ongoing changes in medical practice are likely to increase, rather than decrease doctors’ administrative burden. For instance, physicians are moving into large group practices, but physicians in such practices actually face more paperwork than those in small groups. Similarly, electronic medical records are associated with a higher share of physicians’ working hours being devoted to administration.

Medical Research: What should clinicians and patients take away from your report?

Dr. Woolhandler: Physicians, patients and policymakers need to be advocating for a payment system that lets doctors spend their time on patients, not administration. This means switching to a simple, single payer system, that is, non-profit, tax-funded national health insurance. Private health insurance firms not only generate their own byzantine and expensive bureaucracies, but impose huge bureaucratic burdens on patients and physicians.

Medical Research: What recommendations do you have for future research as a result of this study?

Dr. Woolhandler: Patients and families also face a huge bureaucratic burden dealing with insurance enrollment, copayments, deductibles, referrals and finding doctors in the “narrow networks” that private insurers increasingly impose. Virtually no research has assessed the time spent by patients on such tasks. In addition, there has been no recent research on the amount of time spent by doctors in single payer systems such as Canada’s on paperwork, although anecdotally, physicians there report very little administrative work and relatively high career satisfaction.

Citation: “Administrative work consumes one-sixth of U.S. physicians’ working hours and lowers their career satisfaction,” Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D. International Journal of Health Services, Vol. 44, No. 4.

Marie Benz, M.D., F.A.A.D., is a physician in practice over 30 years. She is editor of MedicalResearch.com.

http://medicalresearch.com/author-interviews/physicians_frustrated_by_administrative_burdens_of_medical_practice/8522/

Administrative burden on U.S. physicians

Administrative Work Consumes One-Sixth of U.S. Physicians’ Working Hours and Lowers Their Career Satisfaction

By Steffie Woolhandler and David U. Himmelstein
International Journal of Health Services, Volume 44, Number 4 / 2014

Abstract:

Doctors often complain about the burden of administrative work, but few studies have quantified how much time clinicians devote to administrative tasks. We quantified the time U.S. physicians spent on administrative tasks, and its relationship to their career satisfaction, based on a nationally representative survey of 4,720 U.S. physicians working 20 or more hours per week in direct patient care. The average doctor spent 8.7 hours per week (16.6% of working hours) on administration. Psychiatrists spent the highest proportion of their time on administration (20.3%), followed by internists (17.3%) and family/general practitioners (17.3%). Pediatricians spent the least amount of time, 6.7 hours per week or 14.1 percent of professional time. Doctors in large practices, those in practices owned by a hospital, and those with financial incentives to reduce services spent more time on administration. More extensive use of electronic medical records was associated with a greater administrative burden. Doctors spending more time on administration had lower career satisfaction, even after controlling for income and other factors. Current trends in U.S. health policy—a shift to employment in large practices, the implementation of electronic medical records, and the increasing prevalence of financial risk sharing—are likely to increase doctors’ paperwork burdens and may decrease their career satisfaction.

From the Discussion

A few studies have examined the amount of time physicians spend on billing and insurance-related paperwork—a narrower definition of administrative work than we used. A 2000 California study estimated billing and insurance-related work consumed 4.9 percent of physician time. In a 2006 survey, physicians reported spending 3 hours per week interacting with private insurance plans, with primary care doctors and solo practitioners reporting slightly higher figures; 81.5 percent perceived that this work was increasing. A companion 2006 survey of office-based private practitioners in Ontario found they spent 2.2 hours per week interacting with insurers (vs. 3.4 hours in the United States when Medicare and Medicaid were included along with private insurers). Differences in the time spent on these tasks by non-physician office staff were even larger; 20.6 hours of nurse time per physician in the United States versus 2.5 hours in Canada; 53.1 hours per week of clerical time in the United States versus 15.9 hours in Canada; and 3.1 hours per week of senior administrators’ time in the United States versus 0.5 hours in Canada.

Much time and money are currently spent on medical billing and paperwork. A simpler system could realize substantial savings, freeing up more resources to expand and improve coverage.

International Journal of Health Services (click on the article for the abstract): https://www.baywood.com/journals/previewjournals.asp?id=0020-7314

Full article: http://org.salsalabs.com/o/307/images/Physician%20admin%20time_IJHS.pdf

PNHP Press Release: https://www.pnhp.org/news/2014/october/administrative-work-consumes-one-sixth-of-us-physicians%E2%80%99-time-and-erodes-their-mor

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Comment:

By Don McCanne, MD

The health care system in the United States is unique for its profound administrative waste. This article by Steffie Woolhandler and David Himmelstein demonstrates the intensity of the administrative burden on physicians – a burden that is correlated with lower career satisfaction.

The good news is that we could reduce that burden and improve satisfaction by adopting a single payer system such as they have in Canada. But then the bad news is that we have left the political agenda in the hands of those who are adept at buying the votes in Congress – especially the insurance and pharmaceutical industries.

It doesn’t have to be this way. After all, we are a democracy, but we have to make the effort to have our voices heard.

****

Bureau of International Information Programs, U.S. Department of State

What Is Democracy?

The essence of democratic action is the active, freely chosen participation of its citizens in the public life of their community and nation. Without this broad, sustaining participation, democracy will begin to wither and become the preserve of a small, select number of groups and organizations.

At a minimum, citizens should educate themselves about the critical issues confronting their society–if only to vote intelligently for candidates running for high office.

http://www.ait.org.tw/infousa/zhtw/docs/whatsdem/whatdm3.htm

Administrative work consumes one-sixth of U.S. physicians’ time and erodes their morale, researchers say

Electronic health records increase doctors’ bureaucratic burden

FOR IMMEDIATE RELEASE, October 23, 2014

Contact: Mark Almberg, communications director PNHP, mark@pnhp.org, (312) 782-6006

The average U.S. doctor spends 16.6 percent of his or her working hours on non-patient-related paperwork, time that might otherwise be spent caring for patients. And the more time doctors spend on such bureaucratic tasks, the unhappier they are about having chosen medicine as a career.

These are some of the findings of a nationwide study by Drs. Steffie Woolhandler and David Himmelstein, internists in the South Bronx who serve as professors of public health at the City University of New York and lecturers in medicine at Harvard Medical School. The study was published this week in the peer-reviewed International Journal of Health Services.

Woolhandler and Himmelstein analyzed confidential data from the 2008 Health Tracking Physician Survey (the most recent data available), which collected information from a nationally representative sample of 4,720 physicians who practiced at least 20 hours per week.

They found that the average doctor spent 8.7 hours per week, or 16.6 percent of their working time, on administration. This excludes patient-related tasks such as writing chart notes, communicating with other doctors and ordering lab tests. It includes tasks such as billing, obtaining insurance approvals, financial and personnel management, and negotiating contracts.

In total, patient-care physicians spent 168.4 million hours on such administrative tasks in 2008. The authors estimate that the total cost of physician time spent on administration in 2014 will amount to $102 billion.

Career satisfaction was lower for physicians who spent more time on administration. “Very satisfied” doctors spent, on average, 16.1 percent of their time on administration. “Very dissatisfied” doctors spent 20.6 percent of their time on such tasks.

Among various specialties, psychiatrists spent the most time on administration (20.3 percent), followed by internists (17.3 percent) and family/general practitioners (17.3 percent). Pediatricians spent the least amount of time (14.1 percent) on non-patient-related administrative tasks and also were the most satisfied group of doctors.

While solo practice was associated with more administrative work, small group practice was not. Doctors practicing in groups of 100 or more actually spent more time (19.7 percent) on such tasks than those in small groups (16.3 percent).

Interestingly, the authors note that physicians who used electronic health records spent more time (17.2 percent for those using entirely electronic records, 18 percent for those using a mix of paper and electronic) on administration than those who used only paper records (15.5 percent).

“Although proponents of electronic medical records have long promised a reduction in doctors’ paperwork,” they write, “we found the reverse is true.”

The authors cite data showing that physicians in Canada spend far less time on administration than do U.S. doctors, and attribute the difference to Canada’s single-payer system, which has greatly simplified billing and reduced bureaucracy.

They point out that the only previous nationally representative survey of this kind was carried out in 1995, and that study showed that administration and insurance-related matters accounted for 13.5 percent of physicians’ total work time. Other, less representative studies, also suggest the bureaucratic burden on physicians has grown over the past two decades.

“American doctors are drowning in paperwork,” said lead author Dr. Woolhandler. “Our study almost certainly understates physicians’ current administrative burden. Since 2008, when the survey we analyzed was collected, tens of thousands of doctors have moved from small private practices with minimal bureaucracy into giant group practices where bureaucracy is rampant. And under the accountable care organizations favored by insurers, more doctors are facing HMO-type incentives to deny care to their patients, a move that our data shows drives up administrative work.”

Dr. Himmelstein commented: “Our crazy health financing system is demoralizing doctors and wasting vast resources. Turning health care into a business means we spend more and more time on billing, insurance paperwork and the bottom line. We need to move to a simple, nonprofit national health insurance system that lets doctors and hospitals focus on patients, not finances.”

“Administrative work consumes one-sixth of U.S. physicians’ working hours and lowers their career satisfaction,” Steffie Woolhandler, M.D., M.P.H., and David U. Himmelstein, M.D. International Journal of Health Services, Vol. 44, No. 4.

Physicians for a National Health Program (www.pnhp.org) is a nonprofit research and education organization of more than 19,000 doctors who support single-payer national health insurance. PNHP had no role in funding or otherwise supporting the study described above.

Single-payer health care is the only sustainable way forward

By Dave Dvorak, M.D.
Duluth News Tribune, Oct. 23, 2014

“Not sustainable.” That was the way PreferredOne CEO Marcus Merz described the circumstances leading to his insurance company’s decision to withdraw from the MNsure exchange.

Now, with double-digit cost increases forecast for many of the plans on the exchange, perhaps it’s time to finally acknowledge what is truly unsustainable: the increasingly costly and complicated patchwork of insurance coverage that passes for an American health care system. 

Spending twice per capita on health care compared to other Western democracies might be defensible if it demonstrated results. But a Commonwealth Fund study earlier this year ranked the U.S. health system dead last among 11 industrialized nations on measures of quality, efficiency and access.

Not sustainable, indeed.

Despite increases in coverage rates under the Affordable Care Act, millions of families on tight budgets are encountering unaffordable deductibles and copays. Take a 60-year-old Minnesota couple earning $63,000 who purchased a specific plan this year on the exchange. If either of them should experience significant illness, they would face more than $25,000 in expenses, including their premium and out-of-pocket costs — 41 percent of their pre-tax income. Not surprisingly, the leading cause of bankruptcy in America is unaffordable health expenses.

The entrenched private insurance industry vigorously promotes the value of choice in our health plans — 84 separate plans will be offered on next year’s exchange — while corralling its “members” (that’s us) into increasingly narrow provider networks. It is our health premiums that pay for those attention-grabbing billboards and commercials, marketing departments, underwriters, lobbyists, eight-figure executive salaries and investor profits. All are costly administrative functions of private insurance that play no role in actual health care.

The good news resides in the ACA’s little-discussed Section1332. Known as the State Innovation Waiver, this provision allows individual states in 2017 to apply for federal waivers to implement their own innovative health systems — provided they can cover at least as many residents as the ACA without adding to the federal deficit. This offers a huge opportunity for Minnesota to get it right.

An increasingly discussed alternative to the status quo is state-based, single-payer reform. Hardly a fringe concept, single-payer was endorsed by 64 percent of Minnesota physicians in a Minnesota Medicine survey in 2007.

More recently, in August, the Minnesota Medical Association, while not taking a position on single-payer, hosted a policy forum to discuss the pros and cons of moving to a state-based single-payer system.

The chief feature of single-payer is a single, unified funding stream that slashes the inefficiencies of the private insurance industry. Single-payer creates transparent and uniform pricing for health services and products. It replaces the cumbersome and costly practice of itemized hospital billing with global annual budgeting, directing more health care dollars toward actual health care rather than webs of hospital administrators and bloated billing departments.

Meanwhile, single-payer keeps the delivery of health care largely private, encouraging market-based competition where it matters — among health care providers.

In its 2012 economic analysis of single-payer reform in Minnesota, the Lewin Group determined that single-payer could provide quality health and dental coverage to every Minnesotan while saving the state a staggering $65 billion in health spending over 10 years. About

95 percent of Minnesotans would spend less on health care — an average savings of $3,512 per year for a median-income Minnesota family.

The conversation is well underway. Through single-payer reform, Minnesota can guarantee fair, affordable and quality health coverage to every individual and family in the state while saving billions. Now that is sustainable.

Dr. Dave Dvorak of Minneapolis is an emergency department physician and a member of the Minnesota chapter of Physicians for a National Health Program (pnhp.org), which advocates for universal health coverage through single-payer reform.

http://www.duluthnewstribune.com/content/local-view-single-payer-health-care-only-sustainable-way-forward

Zarr appointed president-elect of Physicians for a National Health Program

UT School of Public Health, Oct. 22, 2014

Robert Zarr, M.D., M.P.H., an alumnus of The University of Texas School of Public Health, was recently appointed president-elect of the organization Physicians for a National Program (PNHP). Zarr earned an M.P.H. at the School of Public Health, which is part of The University of Texas Health Science Center at Houston (UTHealth), and an M.D. at Baylor College of Medicine.

Zarr is a board-certified pediatrician at Unity Health Care in Washington, where he cares for a low-income and immigrant population. The clinic is a federally qualified health center. Zarr will be presiding over sessions of PNHP’s Annual Meeting in New Orleans on Nov. 15 and will fully assume the office of president on Jan. 1, 2015.

In addition to his work with Unity Health Care and PNHP, Zarr is a strong supporter of physical activity as a prescription for health problems. He works with the Parks Rx program coordinated with the National Park Service and George Washington University. “From my angle, as a physician, I’m literally prescribing parks, prescribing nature now,” says Zarr. He says the research on that should be published soon. (Read more about that here.)

Physicians for a National Health Program is a nonprofit research and educational organization of more than 19,000 members (physicians, retired physicians and medical students) who support single-payer national health insurance. Surveys show that among U.S. physicians, pediatricians tend to be among the most supportive of national health insurance. “It seemed fitting for me to volunteer my time with PNHP because I personally see so much of the unnecessary lack of access to healthcare and all its consequences,” says Zarr.

Zarr will be working with PNHP’s founders, Dr. David Himmelstein and Dr. Steffie Woolhandler; as well as other supporters such as Quentin Young who was a personal physician for Martin Luther King, Jr. “These are people who have really wonderful hearts, who have done so much work to improve all of our lives,” says Zarr. “I’m just so honored that they would even think of me as a peer and a leader in their organization.”

“We’re really about a single issue—which is, in my opinion and the opinions of thousands of other physicians around the country the most important first step—we’ve got to eliminate this financial barrier to seeking care,” says Zarr about PNHP. Zarr mentioned the Dallas Morning News article written by the nephew of Ebola patient Thomas Eric Duncan, which mentions that Duncan was uninsured. “Whether we want to face that fact or not, we know that it plays a very important part in delaying care and in receiving care. Once a person takes the initiative to receive care, it’s undoubtedly a factor that millions—right now we’re still at 42 million—Americans are still uninsured, which is nearly one in six. That’s a lot of people and is a crisis.”

Zarr spoke more about epidemic-sized infectious diseases, specifically Ebola in 2014, and also severe acute respiratory syndrome (S.A.R.S) and the situation that occurred in Asia in 2002-2004. “When you have a looming disaster like this [Ebola], a public-health disaster, people need to know that they can receive care without the stigma of not being able to pay or in the worst case without being deported,” says Zarr. “If you look at S.A.R.S. in China, the government was having a hard time getting ahold of the outbreak and was trying to prevent pandemic. What they found was that people weren’t going to the hospital because they couldn’t pay the bill—they were scared. One of the first things the government did was say, ‘Listen, we’ll pay all the bills: anybody who comes in with S.A.R.S.-related symptoms—it’s all paid for.’ And it worked. It was a very important measure.”

Zarr says not having health insurance delayed Duncan’s decision to go to the emergency room when he was having Ebola symptoms. “We’ve already had one person who didn’t have health insurance and we don’t know all the reasons why he went in when he did, but we know that care is definitely delayed when one does not have health insurance.” Duncan died two days after returning to the hospital for the second time.

When a country has a national health insurance program, Zarr says it is important for the citizens to remember that it is not “free.” Zarr described the National Health System’s formation in the United Kingdom of Great Britain and Northern Ireland in 1948, a few years after the end of World War II. He said the government helped people understand that it would be paid for through taxes in the same way that roads, police, fire departments and schools are paid for. “I think it was a really important move on their part,” Zarr said. “People tend to understand it shouldn’t be free—we do pay for it. And we’re paying for it now; it’s just that it’s not equitable now. Not everybody has equal access and that is the issue that we’ve been grappling with for so long.”

As a physician, Zarr said that the additional M.P.H. degree has given him a good foundation in public health to be an advocate for his patients and people without access to health insurance. “An M.P.H. is really a fantastic supplement to any physician’s career really. I think when you graduate with your M.P.H., you leave there understanding that big picture, which you really need to have in order to effect change on a big scale.”

The PNHP supports two Congressional bills: House bill H.R. 676 and the Senate companion bill 1782. “It’s an important step we need to take so that we can reach the level of outcomes and equity that we haven’t seen ever in this country,” said Zarr about the bills. “We’ve had a lot of discussion about ACA [Affordable Care Act] within our organization [PNHP] and there are a lot of things about ACA that are very good: the expansion of Medicaid, the extension of benefits up to age 26 for a young adult to be on his or her parents’ plan, the elimination of preexisting conditions—but at the end of the day, even by 2016 when it’s supposed to be fully implemented, there’s still going to be around 30 million uninsured and many millions more underinsured. Even though people have an insurance card, they’re still going not to have access to the care they need primarily because they won’t be able to afford the copays and the deductibles. They’re very high, even with the silver plan.”

Zarr is a past president of the Washington, D.C. chapter of the American Academy of Pediatrics and served as a CATCH facilitator in D.C. for five years. He holds adjunct professorships at Children’s National Medical Center and George Washington University.

In addition to his work with PNHP and Parks Rx, he is active in a variety of quality improvement initiatives including asthma management, injury prevention, literacy promotion, breastfeeding awareness, youth advocacy, tuberculosis prevention and compliance with early and periodic screening, diagnostic and treatment standards.

https://sph.uth.edu/2014/10/uthealth-alumnus-zarr-appointed-president-elect-of-physicians-for-a-national-health-program/