PNHP

What the U.S. really needs is a single-payer health system

What the U.S. really needs is a single-payer health system

By Samuel Metz, M.D.
The Oregonian, March 17, 2014

Imagine all your medical information imprinted on one wallet-sized card. Then you lose it. Is this an inconvenience, or a catastrophe?

In France, Taiwan and other countries providing universal health care at lower cost, it’s an inconvenience. Get a replacement, and all is well. No harm, no foul.

But not here. In Oregon, and anywhere in the U.S., your medical records determine the kind of care you get, and maybe if you get any care at all.

It’s a life or death issue.

We are the only country in the world that uses our medical records, along with residence, age, military status, number of co-workers, our employer’s choice of insurance companies, part-time status, income and size of family to determine how much care we will receive and which providers we can see. We then repeat this every time we change residence, age, military status, etc.

No wonder it takes a massively expensive computer system to figure all this out. No wonder it cost Oregon millions of dollars to design this Cover Oregon computer system, repair it, maintain it and change it. And given that thousands of Oregon families need this computer system to work before they can get health care, it’s no wonder we are incensed when this computer system doesn’t work.

None of these millions spent on computer design, repair, maintenance or change goes toward medical care.

All other industrialized countries provide better care to more people for less money than we do. How do they do it? Everyone, sick or healthy, is in one risk pool – human beings. Everyone, rich or poor, receives one set of benefits – treatable conditions are treated. Americans are unhappily unique in insisting health care be dependent upon our age, employer, medical records and all these other factors, but not upon our need.

It is unrealistic to expect our Cover Oregon website to function perfectly for each of the millions of Oregonians simultaneously and desperately attempting to use it. Yet, here we are. We created a website-based health care system in which software separates patients from health care, and now we live with the consequences.

It doesn’t have to be this way. If we want to provide better care to more people for less money, we should learn from countries already achieving it.

Scrap the website and software. Treat every Oregonian the same – you get the care you need when you need it, no matter who you are. Divert the money we pay in premiums and out-of-pocket expenses into a common fund that pays for us all.

This is not a fantasy. Every country in the world that uses such a single payer system provides better care for less money than any of our computer-driven websites could possibly achieve.

Imagine an Oregon in which everyone gets cost-effective care, regardless of medical condition. In this better world, we still risk accidental release of our medical records. But in this better world, the lapse is an embarrassment, not a death sentence.

Samuel Metz, of Portland, is a member of three groups that advocate for publicly funded, universal health care: Health Care for All Oregon, Physicians for a National Health Program, and Mad as Hell Doctors.

http://www.oregonlive.com/opinion/index.ssf/2014/03/what_the_us_really_needs_is_a.html

Stuck out-of-network and vulnerable

Warning: Opting Out Of Your Insurance Plan’s Provider Network Is Risky

By Michelle Andrews
Kaiser Health News, March 18, 2014

Many plans sold on the health insurance marketplaces offer a tradeoff: lower premiums in exchange for limited networks of providers. But consumers who opt for a narrow network plan with the idea that they’ll go out of network when necessary may be taking a big financial risk.

The health law generally places limits on how much consumers can be required to pay out of pocket for medical care (not including premiums). In 2014, the limit for an individual plan is $6,350 and for a family plan, $12,700. But those limits apply only to care provided by doctors and hospitals in a plan’s provider network. There may be a separate out-of-pocket maximum for services provided out of network in marketplace plans, or no cap at all.

Similarly, the health law requires that preventive care such as vaccines, cancer screenings and annual checkups be covered at no cost to consumers in most health plans. If someone uses an out-of-network provider, however, they can be charged.

Going out of network opens the door to higher costs in other ways as well. Plans may require patients to pay a higher copayment or coinsurance for an out-of-network provider. In addition, since the doctors, hospitals and other providers are not under contract with the insurance company, in many states those providers may bill patients for any charges not covered by the insurance, a practice known as “balance billing.” The contracts signed by providers who join plan networks generally contain provisions that prohibit them from balance billing enrollees.

Plans sold on the marketplace are divided into four levels based on the amount of consumer cost sharing required. On average, a bronze plan pays for 60 percent of covered medical services, a silver plan pays for 70 percent, a gold plan, 80 percent, and a platinum plan, 90 percent. But those percentages don’t take any out-of-network care into account.

A McKinsey & Co. analysis of 120 silver-level exchange plans found that 70 percent were narrow network plans, in which at least 30 percent of the area’s largest hospitals are not in the plan, or ultra narrow network plans, in which that number grows to at least 70 percent.

Narrow networks can be a particular problem in HMO-style plans that don’t cover any out-of-network care except for emergency services. According to the analysis by Breakaway Policy Strategies, roughly a third of mid-level silver plans are of this type, typically leaving consumers on the hook for the entire bill if they get care from an out-of-network provider.

The health law does provide protection for consumers when they receive emergency care from a hospital that’s not in their provider’s network. In such instances, health plans can’t charge consumers higher coinsurance or copayments.

However, patients placed on observation status or admitted to the out-of-network hospital from the emergency department are no longer shielded from higher out-of-pocket costs.

“Once the patient is stabilized, the patient will be responsible for whatever the insurer doesn’t pay for that observation or admittance,” says Jeffrey Bettinger, an emergency physician who is chairman of the reimbursement committee of the American College of Emergency Physicians.

Whichever type of plan they choose, the onus is on consumers to dig into the details and make sure they understand what they’re signing up for. There’s a tremendous amount of variability in exchange plans, even among silver level plans, says Richard Smith, executive vice president at Breakaway Policy Strategies.

“I don’t see a lot of standardization,” he says. “Consumers need to be really cognizant. There are design features of these plans that consumers need to be aware of.”

http://www.kaiserhealthnews.org/Stories/2014/March/18/Michelle-Andrews-o…

Most people who have been paying any attention at all are quite aware that health plans inside and outside of the exchanges limit coverage to physicians and hospitals within their contracted networks. Although some plans may also offer limited coverage outside of the networks, it is less clear as to the extent and adequacy of that coverage. This article helps to clarify that issue by showing how muddled the coverage is.

Some of the traps include care provided outside of HMOs, care provided after an emergency patient is stabilized, free preventive services that may not be free outside of the network, services provided within network that are not benefits of the specific plan selected, and so forth. What is particularly treacherous is that, not only do you usually have to pay in full for these services, but your payments may not apply to your maximum out-of-pocket expenses, which can be unlimited out-of-network. The ACA promise that out-of-pocket expenses will be capped for the year ($6,350 for an individual and $12,700 for a family) comes from the same book of promises that gave us “you can keep your plan if you like it.” It is possible to end up with expenses over six figures. That is quite a whack for the person who was trying to do the right thing by buying a qualified insurance plan.

The precise out-of-network coverage depends on the specifications of the plan selected, and there are very few standards with which the plans must comply. So how do you select the right plan?

When people purchase their plans, they usually look first at the premium. Then they look at the deductibles and then the copayments or coinsurance. Usually, when assisted by a plan navigator or equivalent, they will also look at the tax credits for the premiums and the subsidies for cost sharing. Since many benefit from these they often select a silver plan because that is the only tier that includes cost-sharing subsidies.

The next step is to check the list of providers to see if your physician(s) or hospital(s) are on the list. This is where it becomes more tricky since those lists are often difficult to access, and they can be quite unreliable. Even physicians can be confused since they may be included on an insurer’s plan outside of the exchanges, but excluded from the exchange plans, and yet they may not be aware of the exclusion.

Finally, just try to find out the precise rules for coverage of care obtained outside of the network. Since there are very few standards, it is important to know this. The various insurers may approach such charges quite differently. You could end up with only modest additional expenses, but it is not too difficult imagining a six-figure bill when you are admitted to an out-of-network hospital. The insurer may cover the charges in the emergency room, but once the stabilized patient is admitted, she may well be on her own for all additional charges.

Think of how administratively complex the private insurers have already made our system. Then think of the administrative excesses that arise just from handling the muddled out-of-network care. The insurers are forcing upon us even more of their primary product – administrative services – while evading the very purpose of health care coverage by not paying for medical services that the patient needs.

If we had a single payer national health program with first dollar coverage (like many other nations with much lower health care costs) then this out-of-network nonsense would go away. What is really perplexing is why haven’t our people demanded this before now? Don’t facts matter?

In fairness, when we, as experts, think of how much effort we have to put in just to understand these issues, it is no wonder the the insurers and the rest of the medical-industrial complex have been so successful in bamboozling the public at large. We can use the political process to overcome this, but it would require a massive effort. After a couple of decades of working on this, I don’t see it happening. Prove me wrong.

Nine Questions About My New Medical Home

By Matthew Anderson, M.D.
Health Affairs blog, March 17, 2014

Sometime in the past five years — it’s hard for me to say exactly when — I suddenly found myself living in a new home.  I must admit I am still a bit disoriented by how this happened. But it did. People keep telling me that everything will be OK but I am not entirely sure.

For example, in my old home we had occasional family meetings; things are different now. We now have weekly (and monthly) meetings. The many new administrators ask us to complete personality surveys. Once we had to figure out what items we should take from a sinking yacht in the South Pacific (hint: the $100 bill will be useful). Another time we had to decide if we were a “Wow” or a “Thinker.” We are asked to figure out how we can do a better job for them. I guess, like all forms of therapy you don’t get better unless you change.

Despite all these meetings there are a series of things I still don’t understand. I am afraid to raise my hand at the meetings and give the impression I’m a bad sport so I have written my questions down.  Please, please don’t think I am a Luddite who wants to go back to the old home.  In fact, what I dislike most about the new home is precisely the way — even in its differences — it resembles the old home.

1. Is this a home or is it a hostel?

One of the things that drew me to family medicine was the desire to build long-term relationships with families.  I went to weddings and graduations; I was asked to be a godfather. I was there when babies were born and came into bedrooms to declare deaths. I could meet my patients on the street. I had families where I cared for five generations.  At the time insurance companies didn’t generally dictate to people whom they could or could not chose as their doctors. Patients who liked me stayed and those who didn’t went to other doctors. All of this felt something like a home.

All that has changed now.  Pretty much everyone will be on a managed care plan that will limit their choice of providers.  If the system runs as intended, decisions about which doctors patients can see will be made every two years by the rational economic decisions of their employers.  There will be nothing special anymore about the relationship between the doctor and the patient.  As this has been explained to me, it is not really a problem “because you are a member of a team.”

I’ve already lost patients because of this system. And I’ve seen the orphans of other doctors when they come into my practice; they can no longer see their old family doctor because he or she isn’t in their new plan. I console them and then spend time reconstructing their health and social histories. I repeat labs, perhaps even vaccines given by the other physician.   It’s hard to see that this makes clinical, emotional, or economic sense.  And when will they have to leave my panel?

In a system where physician choice is guided by the commercial interests of employers and insurers, is it really possible to speak of a medical home?

2. Will my old friends still be welcome in my new home?

One of the things that most worries me is “Pay for Performance,” or P4P.  Mind you, I don’t think it’s wrong to evaluate physician performance, although I wonder if the metrics being used are the right ones. I am not sure, for example, that the skill that best characterizes me is my ability to order flu shots.  It’s also not at all clear that paying doctors for hitting targets actually improves any outcomes. Nonetheless, my income will increasingly depend upon hitting targets dictated by the insurance companies. But to be honest, I am not even sure who generates the targets. It isn’t us. And in this patient-centered home, it is not the patients.

P4P is very worrisome. Many of my patients are not necessarily what we, as residents, used to call “citizens.”  Many of them have drug histories, some have done time, a good proportion don’t read or write. They are often skeptical of my brand of medicine, and many are struggling with mental illness.  Their insurance status is often precarious; even if they wanted to get care, it is often unavailable to them.  Experience would suggest that this group will not have excellent clinical outcomes.  Are my old friends now going to cost me money?

It wouldn’t be hard to figure out ways to get this group of people off my panel and to get more “citizens” on it. It would make me look good. It would make the clinic look good. And it’s what the rational economic incentives offered me would dictate. Why, then, don’t I want to do it? Is there something wrong with my attitude?

3. Does Mommy love me or is she just paid to say so?

Recently a patient asked me if he should get a flu shot or not.  I told him I was getting flu shot and that I thought he should too. I thought this was the right answer despite my (ever deepening) skepticism about vaccines and their regulation.

Behind my patient’s question was the implicit assumption that I would be providing him with unbiased, expert advice that was not influenced by commercial considerations.  I think he would have felt less sure of my answer had he known that part of my salary depended upon his getting a flu shot.  Is it fair for me to have given him any advice on this matter without disclosing my economic interest in the answer?  I must admit, sadly, that P4P makes me feel more than ever like a poorly paid pimp for the medical industrial complex.  And I wonder how I will feel the next time I go see my doctor and ask for his or her advice. Should I ask him if he is being paid to get me to do something Aetna has decided is important?

The problem is that once communication is purchased (in secret) it becomes impossible to trust anyone.

4. Why are we playing computer games during family time?

The moments I used to enjoy most were those when I sat down in front of a patient and we talked. This was the time to enjoy the immense privilege of entering into another person’s reality and engaging with it.

The EMR has fundamentally altered this relationship in ways that I am still struggling with.  There is much less eye contact with my patients since I am writing on a keyboard, often sitting crosswise to him or her.  Sometimes I even have to sit with my back to the patient. The content of the interview is dictated by a series of menus whose logical progression is unclear to me; I can’t imagine what my patients conjecture.

Like many large medical systems we have several EMRs and they don’t talk to one another. During a typical encounter I am switching back and forth on the computer between software A and software B (perhaps even opening C & D), all the while trying to maintain a conversation with someone in English (or in their own language). It may be just my inability to multi-task and I am sure that someday we will have (one) good EMR.  But right now it seems to me that the multiple EMR’s are a massive barrier between my patients and me. They feel very unsafe. Wouldn’t it have been better to have thoroughly tested these systems first?  Or was this another rational, economic decision?

5. Are there any family secrets left?

In my old home medical information was relatively isolated in a paper chart located in one physical space; I must say I hated running up and down to the chart room and longed for an EMR. But nowadays when I type something into the computer literally thousands of people across the medical center can access it.  My notes are sent to insurance companies to provide verification of need. The pharmaceutical companies mine (and have mined) all our prescription data. They know more about what I have prescribed than our EMR does.

I think about this when I go to visit my own doctor who belongs to a different hospital. How many people — either strangers or acquaintances — will now be able to read everything I have told him?  It has made me circumspect. Paper charts are so 20th century, but I do wish that there were real protections for patient information including my own. Remember that your colleague or clinic supervisor can — with a few strokes of their fingers — open your EMR.  Wouldn’t it have been better to discuss this matter thoroughly first? Or is private patient data just one more commodity to be bought and sold by billion dollar corporations?

6. Everyone tells me how important I am, so why is my allowance being cut?

This is the part that puzzles me the most.  At a recent Grand Rounds we were told that everyone thought primary care providers were the backbone of the health care system.  President Obama said so. Orin Hatch said so. The ACA said so. The Republicans said so.  Even IBM loves family doctors and IBM points out that they are buying the care so they should be able to get what they want.

Yet when I look at my paycheck now it is less today — in real terms — than it was when I was hired in 1995.  I worked hard in 1995 and I work hard now.  I regularly work two or more weeks without a day off.  This is the life I love, but I can easily understand why medical students would decide upon a different career. They see how hard we family doctors work, they hear about our salaries, and they are socialized in a medical culture that values technical expertise and knowing more and more about less and less.  It almost seems like all this talk about the importance of primary care is just that: happy talk designed to keep us working. I suspect medical students are smart enough to figure this out and continue to avoid our specialty.

We are not flourishing as a specialty and our leadership is far too busy talking about the promised land of the PCMH.

7. Do I have to go to Church now?

One of the things I like best about medicine is that — despite its very imperfect realization — medicine aspires to be a scientific pursuit based on evidence.  But the current crop of Administrators (MD’s freshly minted with their MBA’s or a course at Harvard Business School) subscribe to a different religion: the compelling anecdote dressed up as a case study.  Advanced Access came to our clinic five years ago on the basis of a case study series in JAMA.  Would we give a new hypertensive drug based on a case series?  Why are management decisions not held to the same level of careful scrutiny we give to clinical interventions?  Why are we told that P4P will be implemented despite the lack of good evidence “because insurers are paying for it”?

I see that same problem in the enthusiastic and relentless pursuit of better patient satisfaction scores.  Patients are constantly reminded that “we strive for five” and managers are rewarded when satisfaction scores are high.  This passes for good administrative practice or even as hardheaded business thinking.  But basic research principles tell us that if you want an honest answer to a question you don’t begin by suggesting the responses.  What would we think of a clinical trial where the Principal Investigator met weekly with his or her evaluation team to review blood pressure readings and told them that he wanted better results?  Or where the PI offered money to the research team that could produce the best results?  We would consider such behavior highly unethical. Why? Because research strives to produce honest results, not those that favor the hypothesis of the investigator.

When Administrators tell staff to tell patients that we strive for five, what are they doing? Both being dishonest and biasing the results to serve their own interests. This is not science; this is hucksterism.

Of course, it is not really the administrators’ fault.  They are good people. I like the place I work because there are so many good people there. The problem doesn’t lie with the people, it lies with the system.

8. Can we get some family therapy?

We are told that the new home is “patient centered.”  But what does that mean?  Patients certainly weren’t involved in setting it up, nor are they involved in its management. The main way they can provide feedback is via surveys, but these surveys are conducted in a way that biases results. Indeed, by almost any measure the patient seems to be the last one taken into consideration.

9. Can’t we afford a better home?

It may sound like I am a bit homesick but this is not true. In fact, I am concerned that the new medical home has all the defects of the old home: balkanization of information, over-reliance on technology, medicalization, disrupted care, waste, inefficiency, values that favor the privileged, the rigid hierarchies that keep people from working well together, inattention to the needs of patients — except now it’s all electric.  It’s like giving steroids to someone on acne. The problems just get uglier.

There was a time when family medicine saw itself as a counter-culture in medicine with a mission to incorporate a different set of values.  Our job should be to improve the wellbeing and health of our patients and their communities, not the bottom line of the corporations who thrive off our labor.

Such a dream will not happen until health care is seen as a public good instead of a private commodity.  A national health system, it seems, is the only economically rational and humane way forward.

http://healthaffairs.org/blog/2014/03/17/nine-questions-about-my-new-medical-home/

“42,000 Canadians come to the United States for care” – Really?

Hearing: “Access and Cost: What the U.S. Health Care System Can Learn from Other Countries”

Testimony of Sally C. Pipes, President and CEO, Pacific Research Institute
U.S. Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging, March 11, 2014

Those Canadians who can afford to do so have simply opted out of their healthcare system. An enormous number jump the queue for care in their native land and travel to the United States to receive medical attention. In 2012, over 42,000 Canadians crossed the border to get treated.

http://www.help.senate.gov/imo/media/doc/Pipes.pdf

****

Frasier Institute Reports:

Leaving Canada for Medical Care 2010
Estimated number of patients receiving treatment outside Canada, 2010: 44,794
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/articles/leaving-canada-for-medical-care.pdf

Leaving Canada for Medical Care 2011
Estimated number of patients receiving treatment outside Canada, 2011: 46,159
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/articles/leaving-canada-for-medical-care-2011-ff0712.pdf

Leaving Canada for Medical Care 2012
Estimated number of patients receiving treatment outside Canada, 2012: 42,173
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/articles/leaving-canada-for-medical-care-2012.pdf

Waiting Your Turn: Wait Times for Health Care in Canada 2011
Average Percentage of Patients Receiving Treatment Outside of Canada, 2011: 1.0%
(See Page 58, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2011.pdf

Waiting Your Turn: Wait Times for Health Care in Canada 2012
Average Percentage of Patients Receiving Treatment Outside of Canada, 2012: 0.9%
(See Page 62, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2012.pdf

Waiting Your Turn: Wait Times for Health Care in Canada 2013
Average Percentage of Patients Receiving Treatment Outside of Canada, 2013: 0.9%
(See Page 64, Table 11)
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-news/research/publications/waiting-your-turn-2013.pdf

****

Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States

By Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer and Robert G. Evans
Health Affairs, May 2002

Abstract

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://content.healthaffairs.org/content/21/3/19.abstract

Comment:

By Don McCanne, M.D.

Each year the Fraser Institute of Canada issues a report claiming that over 40,000 patients leave Canada for medical care. Yet a highly credible study done over a decade ago revealed that many of these supposed patients were merely “phantoms in the snow” and that this is another “zombie idea” that, on logic or evidence, is “intellectually dead” but “can never be laid to rest because (the concept is) useful to some powerful interests.” So it is important to understand the source of the Fraser numbers.

Warning: The following is wonkish

As part of their annual survey of specialists to determine waiting times in Canada, the Fraser Institute asks the following question (the last question of their survey):

12. Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:

In another province? ______ % Outside of Canada? ______ %

Then, within each of twelve specialties in each of the ten provinces, they average the percent of patients who reportedly obtain care outside of Canada, as estimated by the practitioners of those specialities. If you look at Table 11 in any of the “Waiting Your Turn” reports listed above (choose 2013 as the latest example), you will see that this creates a grid of 120 percentages. Averages are obtained for each province (bottom line) and for each specialty (column on the right). These are then averaged to get the final percentage for all of Canada – 0.9% for 2013.

Stop here and think about that. Each practitioner was asked to estimate a percentage of his or her patients who left Canada for care (not specifically for care in the United States as Canada has a very large immigrant population – about one-fifth were born outside of Canada). If they had been asked for specific numbers, each may have been able to make a fairly reasonable guesstimate. But they were asked for a percentage. If there were not very many then the lowest full integer might come to mind – one percent (“Oh, it can’t be more than one percent”). In fact, 37% of the 120 sections of the grid reported zero percentages of patients leaving the country for care – probably a more realistic assessment since those specialists likely couldn’t remember any patients who left. Nevertheless, the majority estimated percentages well below one percent, i.e., there weren’t very many.

But look at Table 11 for 2013. There is quite a wide variation in the 120 results listed. For 2013 that ranged from 0.0% (the most common response) to 5.0%. The responses of 1.0% and higher were the outliers. With the outliers, it is difficult to imagine why a given specialty in a given province would have such a high number of patients leaving the country for health care. When we hear about delays in care in Canada, the most common one is orthopedics – joint replacement, etc. Yet in all of Canada, orthopedics is listed at 0.7%, below the 0.9% average for all specialties combined. It is suspicious that some physicians, intentionally or unintentionally, may be making high estimates which would skew the numbers upwards.

Let’s look at Table 11 for 2011 and 2012 as well as 2013. Urology in British Columbia was 1.3% in 2011, 2.0% in 2012, and 3.8% in 2013. Plastic surgery in British Columbia was 7.8%, 1.3%, and 0.4% in those same years. Cardiovascular survey in New Brunswick was 0.0%, 3.0%, and 0.5%. Internal Medicine in Manitoba was 3.4%, 0.5%, and 0.3%. Radiation oncology in New Brunswick was 0.5%, 7.0%, and zero. Obviously there is a large scatter in the high outliers that changes from year to year. Further, the entire population of specialists surveyed in 2013 totaled only 2,160 physicians scattered amongst 120 categories in the grid. It is quite obvious that only a few individual outliers, who either guessed high or wanted to make a political point, were able to skew the percentages upward. Eliminating the outliers likely would reduce the net percentage in half and maybe more.

For the next step, the Fraser Institute “(combined) these percentages with the number of procedures performed in each province and in each medical specialty (to give) an estimate of the number of Canadians who actually received treatment outside the country.” The results are in Table 1 of each of the three reports, “Leaving Canada for Medical Care.” If their percentages were correct (which they likely are not) and the tally of the procedures were correct (uncertain) then this calculation might give a very rough approximation of the number of procedures performed outside of Canada for each of the 120 categories of the grid. But talk about soft numbers.

They then add a “residual” number of procedures for which people are waiting. “To estimate this residual number, the number of non-emergency operations not contained in the survey that are done in each province annually must be used” – using CIHI and other data which they “pro-rated.” This “residual” for 2012 was 18,265 of the 42,173 total estimated to have exited Canada for health care. It’s a convenient number to boost the figures, even if they are “operations not contained in the survey.”

Talk about phantoms in the snow. This data is almost useless for estimating the number of Canadians who leave Canada for health care, much less whether or not they received it in the United States.

More importantly, the premise of those who use these unreliable numbers of patients exiting Canada for care is that single payer financing results in excessive queues which then triggers this exit. That should not necessarily follow since queues can be tamed if the stewards of the system are attentive to system capacity and queue management. Many nations with comprehensive systems do not have problems with queues.

In contrast, in the United States, the financial barriers to care (that do not exist in Canada) are so great that tens of millions who need care do not even gain a place in the queue – rationing based on ability to pay. Only a fool would recommend our callous system over Canada’s egalitarian single payer system.

****

For those who read this far, it might be worth your time to look at one more item. The “Waiting Your Turn” reports are the same reports that are used each year to claim that Canadians have intolerable delays in accessing their health care. For the 2013 Waiting Your Turn report, look at Chart 6 on page 10. Except for plastic surgery, orthopedics and internal medicine (not primary care), the actual median time between an appointment with a specialist and treatment is quite close to the median time that the specialists deemed to be a reasonable wait. And where there are problems, they are working on it.

More reliable data on wait times in Canada is available through the Canadian Institute for Health Information:

http://www.cihi.ca/CIHI-ext-portal/internet/EN/subtheme/health+system+performance/access+and+wait+times/cihi010647

Universal coverage remains a big deal

By Philip Verhoef, MD, PhD and Stephen Kemble, MD
KevinMD.com, March 16, 2014

Recently JAMA published a special theme issue on critical issues in U.S. health care. Among the contributors was Dr. Ezekiel Emanuel, the oncologist, bioethicist and former White House adviser on health policy.

In his article, “Going to the Moon in Health Care: Medicine’s Big Hairy Audacious Goal (BHAG),” Emanuel argues that contemporary medicine is in need of vision, an overarching, aspirational goal “like going to the moon that can make an organization — or a nation — stretch beyond what it thought was possible to achieve remarkable things.”

He asserts that medicine has no such vision today. In the past, medicine’s BHAG was universal coverage, but now, he suggests, that’s passé.

The goal of universal coverage may have been “transformative for the U.S. polity but not really for the U.S. health system,” he writes. “The Affordable Care Act may result in universal coverage, but that goal no longer has the qualities of a BHAG.”

We strongly disagree. Universal coverage remains a “Big Hairy Ambitious Goal,” especially in view of official estimates that our nation will still have 31 million uninsured people in 2024.

One has to wonder: When Emanuel argues that the goal of universal care “was not transformative for the U.S. health system,” is he speaking of corporate interests, such as the insurance industry? Clearly he does not mean physicians, a majority of whom now support government action to establish national health insurance, which would assure truly universal coverage.

Offering his own candidate for a winning BHAG, Emanuel proposes the financial goal of capping health care cost increases relative to the GDP, or in his words, “By 2020, per capita health care costs will increase no more than gross domestic product (GDP) + 0%.”

Cost control is indeed a worthy and urgent goal, given that economists are unanimous in predicting that health care costs will continue to rise under the Affordable Care Act. But the remedies that Emanuel has traditionally prescribed for this problem fall far short of what is needed.

In point of fact, a single-payer, government-funded system would be the easiest way to control health care costs — and it would also achieve the appropriate BHAG of universal coverage.

A single payer universal insurance system would control costs by:

  • Eliminating the administrative waste and profiteering associated with insurance companies. Far more of the health care dollar would go to health care, not to advertising, administration, or assuring shareholder profits.
  • Allowing the government to negotiate pricing for medications and services to lower costs.
  • Eliminating the need for the poor and uninsured to seek uncompensated health care from ERs.
  • Facilitating a healthier, more productive work force.
  • Employing global budgeting for hospitals, eliminating the incentives driving their role in health care cost escalation.

Emanuel and others have argued that fee-for-service is the driver of excessive health care costs, but there is scant evidence proving this. Other countries provide universal high-quality coverage under a fee-for-service system and are still able to control health care costs.

Obamacare cannot lead to universal coverage. By maintaining the insurance industry’s role as a middleman, it will serve to ensure that health care costs cannot be reined in without draconian restrictions on needed care.

Emanuel rightly suggests that reining in costs will require focusing on outpatient management of patients with chronic conditions. However, the biggest obstacle to this is inadequate access due to uninsurance and underinsurance, not lack of technological tracking of physiologic indicators.

Both access to care and quality improvement would be much easier in a single-payer system.

Emanuel has reframed the crisis in the U.S. health care system as one of cost instead of the approximately 100 million Americans who lack health insurance or have insurance that does not enable appropriate care, leading to many thousands of deaths per year. We suggest that elimination of this travesty is the most important BHAG for physicians and that the solution is a single-payer system.

Philip Verhoef is critical care physician. Stephen Kemble is an internal medicine physician.

http://www.kevinmd.com/blog/2014/03/universal-coverage-remains-big-deal.html

“42,000 Canadians come to the United States for care” – Really?

Hearing: “Access and Cost: What the U.S. Health Care System Can Learn from Other Countries”

Testimony of Sally C. Pipes, President and CEO, Pacific Research Institute
U.S. Senate Committee on Health, Education, Labor and Pensions, Subcommittee on Primary Health and Aging, March 11, 2014

Those Canadians who can afford to do so have simply opted out of their healthcare system. An enormous number jump the queue for care in their native land and travel to the United States to receive medical attention. In 2012, over 42,000 Canadians crossed the border to get treated.

http://www.help.senate.gov/imo/media/doc/Pipes.pdf

****

Frasier Institute Reports:

Leaving Canada for Medical Care 2010
Estimated number of patients receiving treatment outside Canada, 2010: 44,794
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Leaving Canada for Medical Care 2011
Estimated number of patients receiving treatment outside Canada, 2011: 46,159
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Leaving Canada for Medical Care 2012
Estimated number of patients receiving treatment outside Canada, 2012: 42,173
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

Waiting Your Turn: Wait Times for Health Care in Canada 2011
Average Percentage of Patients Receiving Treatment Outside of Canada, 2011: 1.0%
(See Page 58, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research…

Waiting Your Turn: Wait Times for Health Care in Canada 2012
Average Percentage of Patients Receiving Treatment Outside of Canada, 2012: 0.9%
(See Page 62, Table 11)
https://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research…

Waiting Your Turn: Wait Times for Health Care in Canada 2013
Average Percentage of Patients Receiving Treatment Outside of Canada, 2013: 0.9%
(See Page 64, Table 11)
http://www.fraserinstitute.org/uploadedFiles/fraser-ca/Content/research-…

****

Phantoms In The Snow: Canadians’ Use Of Health Care Services In The United States

By Steven J. Katz, Karen Cardiff, Marina Pascali, Morris L. Barer and Robert G. Evans
Health Affairs, May 2002

Abstract

To examine the extent to which Canadian residents seek medical care across the border, we collected data about Canadians’ use of services from ambulatory care facilities and hospitals located in Michigan, New York State, and Washington State during 1994–1998. We also collected information from several Canadian sources, including the 1996 National Population Health Survey, the provincial Ministries of Health, and the Canadian Life and Health Insurance Association. Results from these sources do not support the widespread perception that Canadian residents seek care extensively in the United States. Indeed, the numbers found are so small as to be barely detectible relative to the use of care by Canadians at home.

Phantoms in the snow.

Despite the evidence presented in our study, the Canadian border-crossing claims will probably persist. The tension between payers and providers is real, inevitable, and permanent, and claims that serve the interests of either party will continue to be independent of the evidentiary base. Debates over health policy furnish a number of examples of these “zombies”—ideas that, on logic or evidence, are intellectually dead—that can never be laid to rest because they are useful to some powerful interests. The phantom hordes of Canadian medical refugees are likely to remain among them.

http://content.healthaffairs.org/content/21/3/19.abstract

Each year the Fraser Institute of Canada issues a report claiming that over 40,000 patients leave Canada for medical care. Yet a highly credible study done over a decade ago revealed that many of these supposed patients were merely “phantoms in the snow” and that this is another “zombie idea” that, on logic or evidence, is “intellectually dead” but “can never be laid to rest because (the concept is) useful to some powerful interests.” So it is important to understand the source of the Fraser numbers.

Warning: The following is wonkish

As part of their annual survey of specialists to determine waiting times in Canada, the Fraser Institute asks the following question (the last question of their survey):

12. Approximately what percentage of your patients received non-emergency medical treatment in the past 12 months:

In another province? ______ % Outside of Canada? ______ %

Then, within each of twelve specialties in each of the ten provinces, they average the percent of patients who reportedly obtain care outside of Canada, as estimated by the practitioners of those specialities. If you look at Table 11 in any of the “Waiting Your Turn” reports listed above (choose 2013 as the latest example), you will see that this creates a grid of 120 percentages. Averages are obtained for each province (bottom line) and for each specialty (column on the right). These are then averaged to get the final percentage for all of Canada – 0.9% for 2013.

Stop here and think about that. Each practitioner was asked to estimate a percentage of his or her patients who left Canada for care (not specifically for care in the United States as Canada has a very large immigrant population – about one-fifth were born outside of Canada). If they had been asked for specific numbers, each may have been able to make a fairly reasonable guesstimate. But they were asked for a percentage. If there were not very many then the lowest full integer might come to mind – one percent (“Oh, it can’t be more than one percent”). In fact, 37% of the 120 sections of the grid reported zero percentages of patients leaving the country for care – probably a more realistic assessment since those specialists likely couldn’t remember any patients who left. Nevertheless, the majority estimated percentages well below one percent, i.e., there weren’t very many.

But look at Table 11 for 2013. There is quite a wide variation in the 120 results listed. For 2013 that ranged from 0.0% (the most common response) to 5.0%. The responses of 1.0% and higher were the outliers. With the outliers, it is difficult to imagine why a given specialty in a given province would have such a high number of patients leaving the country for health care. When we hear about delays in care in Canada, the most common one is orthopedics – joint replacement, etc. Yet in all of Canada, orthopedics is listed at 0.7%, below the 0.9% average for all specialties combined. It is suspicious that some physicians, intentionally or unintentionally, may be making high estimates which would skew the numbers upwards.

Let’s look at Table 11 for 2011 and 2012 as well as 2013. Urology in British Columbia was 1.3% in 2011, 2.0% in 2012, and 3.8% in 2013. Plastic surgery in British Columbia was 7.8%, 1.3%, and 0.4% in those same years. Cardiovascular survey in New Brunswick was 0.0%, 3.0%, and 0.5%. Internal Medicine in Manitoba was 3.4%, 0.5%, and 0.3%. Radiation oncology in New Brunswick was 0.5%, 7.0%, and zero. Obviously there is a large scatter in the high outliers that changes from year to year. Further, the entire population of specialists surveyed in 2013 totaled only 2,160 physicians scattered amongst 120 categories in the grid. It is quite obvious that only a few individual outliers, who either guessed high or wanted to make a political point, were able to skew the percentages upward. Eliminating the outliers likely would reduce the net percentage in half and maybe more.

For the next step, the Fraser Institute “(combined) these percentages with the number of procedures performed in each province and in each medical specialty (to give) an estimate of the number of Canadians who actually received treatment outside the country.” The results are in Table 1 of each of the three reports, “Leaving Canada for Medical Care.” If their percentages were correct (which they likely are not) and the tally of the procedures were correct (uncertain) then this calculation might give a very rough approximation of the number of procedures performed outside of Canada for each of the 120 categories of the grid. But talk about soft numbers.

They then add a “residual” number of procedures for which people are waiting. “To estimate this residual number, the number of non-emergency operations not contained in the survey that are done in each province annually must be used” – using CIHI and other data which they “pro-rated.” This “residual” for 2012 was 18,265 of the 42,173 total estimated to have exited Canada for health care. It’s a convenient number to boost the figures, even if they are “operations not contained in the survey.”

Talk about phantoms in the snow. This data is almost useless for estimating the number of Canadians who leave Canada for health care, much less whether or not they received it in the United States.

More importantly, the premise of those who use these unreliable numbers of patients exiting Canada for care is that single payer financing results in excessive queues which then triggers this exit. That should not necessarily follow since queues can be tamed if the stewards of the system are attentive to system capacity and queue management. Many nations with comprehensive systems do not have problems with queues.

In contrast, in the United States, the financial barriers to care (that do not exist in Canada) are so great that tens of millions who need care do not even gain a place in the queue – rationing based on ability to pay. Only a fool would recommend our callous system over Canada’s egalitarian single payer system.

****

For those who read this far, it might be worth your time to look at one more item. The “Waiting Your Turn” reports are the same reports that are used each year to claim that Canadians have intolerable delays in accessing their health care. For the 2013 Waiting Your Turn report, look at Chart 6 on page 10. Except for plastic surgery, orthopedics and internal medicine (not primary care), the actual median time between an appointment with a specialist and treatment is quite close to the median time that the specialists deemed to be a reasonable wait. And where there are problems, they are working on it.

More reliable data on wait times in Canada is available through the Canadian Institute for Health Information:

http://www.cihi.ca/CIHI-ext-portal/internet/EN/subtheme/health+system+pe…

Canada’s Dr. Danielle Martin educates Sen. Richard Burr on single payer

Health Care: U.S. vs. Canada

YouTube, March 12, 2014

On March 11, 2014, several authorities on single payer health care systems of other nations testified before a committee of the United States Senate, chaired by Sen. Bernie Sanders. The hearing was not only the topic of a recent Quote of the Day (March 12), it also has been covered extensively in the media and on the Internet throughout the United States and Canada.

It was the responses of Dr. Danielle Martin of Canada to the questions from Committee Ranking Member Sen. Richard Burr, that caused this story to go viral. For those who missed it, the 7 minute segment that includes the exchange between Dr. Martin and Sen. Burr can be viewed at this YouTube link: http://www.youtube.com/watch?v=iYOf6hXGx6M

You can read more about this exchange by Googling “Danielle Martin.” Some of the other coverage:

National Post: “Toronto doctor smacks down U.S. Senate question on Canadian waitlist deaths”: http://news.nationalpost.com/2014/03/12/toronto-doctor-smacks-down-u-s-senate-question-on-canadian-waitlist-deaths/
Los Angeles Times: “Watch an expert teach a smug U.S. senator about Canadian healthcare”: http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story
Huffington Post: “Watch This Doctor Totally School An Anti-Obamacare Senator On Health Care”: http://www.huffingtonpost.com/2014/03/13/danielle-martin-richard-burr_n_4958164.html
Huffington Post Canada: “Canadian Doctor Gives U.S. Senator A Clinic On Public Health Care”: http://www.huffingtonpost.ca/2014/03/13/canadian-doctor-us-senator-health-care_n_4956468.html
CBC.ca (audio): “Canadian doctor schools U.S. Senator on public health care”: http://www.cbc.ca/asithappens/features/2014/03/12/canadian-doctor-schools-us-senator-on-public-health-care/
MSNBC: The Rachel Maddow Show (3/14/14, Ari Melber, guest host): http://www.msnbc.com/rachel-maddow-show
The Maddow Blog: “Martin 1, Burr 0″: http://www.msnbc.com/rachel-maddow-show/martin-1-burr-0#break
Salon: “Canadian doctor makes anti-Obamacare senator look like a buffoon”: http://www.salon.com/2014/03/13/canadian_doctor_makes_anti_obamacare_senator_look_like_a_buffoon/
Toronto Star: “Toronto doctor smacks down U.S. senators’ myths about Canadian health care”: http://www.thestar.com/life/health_wellness/2014/03/13/toronto_doctor_smacks_down_us_senators_myths_about_canadian_health_care.html
Canada.com: “Watch: Canadian doctor schools American senator on health care”: http://o.canada.com/health/danielle-martin-richard-burr-health-care-410599/
Huffington Post Canada: “Republicans Ruin Health Care By Ignoring Jesus (And Canada)”: http://www.huffingtonpost.ca/michael-bolen/canada-america-health-care-christian-nation_b_4957509.html

Well, you get the point.

For those interested in viewing the entire hearing (1 hour, 45 minutes), or wish to download witness statements: http://www.help.senate.gov/hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe

Canada’s Dr. Danielle Martin educates Sen. Richard Burr on single payer

Health Care: U.S. vs. Canada

YouTube, March 12, 2014

On March 11, 2014, several authorities on single payer health care systems of other nations testified before a committee of the United States Senate, chaired by Sen. Bernie Sanders. The hearing was not only the topic of a recent Quote of the Day (March 12), it also has been covered extensively in the media and on the Internet throughout the United States and Canada.

It was the responses of Dr. Danielle Martin of Canada to the questions from Committee Ranking Member Sen. Richard Burr, that caused this story to go viral. For those who missed it, the 7 minute segment that includes the exchange between Dr. Martin and Sen. Burr can be viewed at this YouTube link: http://www.youtube.com/watch?v=iYOf6hXGx6M

You can read more about this exchange by Googling “Danielle Martin.” Some of the other coverage:

National Post: “Toronto doctor smacks down U.S. Senate question on Canadian waitlist deaths”: http://news.nationalpost.com/2014/03/12/toronto-doctor-smacks-down-u-s-senate-question-on-canadian-waitlist-deaths/
Los Angeles Times: “Watch an expert teach a smug U.S. senator about Canadian healthcare”:http://www.latimes.com/business/hiltzik/la-fi-mh-watch-a-canadian-20140312,0,2995139.story
Huffington Post: “Watch This Doctor Totally School An Anti-Obamacare Senator On Health Care”: http://www.huffingtonpost.com/2014/03/13/danielle-martin-richard-burr_n_4958164.html
Huffington Post Canada: “Canadian Doctor Gives U.S. Senator A Clinic On Public Health Care”: http://www.huffingtonpost.ca/2014/03/13/canadian-doctor-us-senator-health-care_n_4956468.html
CBC.ca (audio): “Canadian doctor schools U.S. Senator on public health care”:http://www.cbc.ca/asithappens/features/2014/03/12/canadian-doctor-schools-us-senator-on-public-health-care/
MSNBC: The Rachel Maddow Show (3/14/14, Ari Melber, guest host):http://www.msnbc.com/rachel-maddow-show
The Maddow Blog: “Martin 1, Burr 0″: http://www.msnbc.com/rachel-maddow-show/martin-1-burr-0#break
Salon: “Canadian doctor makes anti-Obamacare senator look like a buffoon”:http://www.salon.com/2014/03/13/canadian_doctor_makes_anti_obamacare_senator_look_like_a_buffoon/
Toronto Star: “Toronto doctor smacks down U.S. senators’ myths about Canadian health care”:http://www.thestar.com/life/health_wellness/2014/03/13/toronto_doctor_smacks_down_us_senators_myths_about_canadian_health_care.html
Canada.com: “Watch: Canadian doctor schools American senator on health care”:http://o.canada.com/health/danielle-martin-richard-burr-health-care-410599/
Huffington Post Canada: “Republicans Ruin Health Care By Ignoring Jesus (And Canada)”:http://www.huffingtonpost.ca/michael-bolen/canada-america-health-care-christian-nation_b_4957509.html

Well, you get the point.

For those interested in viewing the entire hearing (1 hour, 45 minutes), or wish to download witness statements: http://www.help.senate.gov/hearings/hearing/?id=8acab996-5056-a032-522e-e39ca45fcfbe

Half will have change of eligibility for Medicaid or subsidies within one year

Medicaid And Marketplace Eligibility Changes Will Occur Often In All States; Policy Options Can Ease Impact

By Benjamin D. Sommers, John A. Graves, Katherine Swartz and Sara Rosenbaum

Health Affairs, April 2014 (online March 12, 2014)

Beginning January 1, 2014, the Affordable Care Act (ACA) established two pathways to health insurance for nonelderly US citizens and legal residents. The first was an expansion of Medicaid coverage for people with annual incomes of up to 138 percent of the federal poverty level in states that elected to expand their programs. The second pathway was subsidizing private coverage purchased via health insurance Marketplaces for people with incomes of 138–400 percent of poverty who do not have an offer of affordable coverage through an employer. The pathways are designed to work in tandem, but a major challenge is how to promote continuity of coverage and health care for people when their incomes and life circumstances cause them to transition between Medicaid and subsidized private coverage.

In states that opt out of the ACA’s Medicaid expansion, changes in income or family circumstance will lead many people to lose coverage entirely unless they qualify for coverage under one of the traditional categories of Medicaid eligibility: pregnancy, disability, or being the impoverished parent of a minor child. A less stark problem that presents a different set of challenges will occur in states that do expand Medicaid: the potential for moving between Medicaid and Marketplace coverage.

Both of these types of “churning”—loss of coverage and frequent transitions in the source of coverage—can cause difficulties. The total loss of coverage raises the most serious problems in terms of access to care, but frequent transitions across coverage pathways also raise important issues for beneficiaries, health plans, providers, and policy makers. From one year to the next or during any given year, many individuals and families will experience changes in eligibility either for Medicaid or for Marketplace coverage. These eligibility changes could lead to both gaps in coverage and disruptions in the continuity of care, because people might have to find new providers or change their existing health treatments if their new insurance plan uses a different provider network or covers different services than their old plan did.

Previous research has estimated that approximately half of low-income adults might experience a change in income or family circumstances leading them to transition from Medicaid to Marketplace coverage (or vice versa) each year.

From the Discussion

We estimated that approximately half (plus or minus 5 percentage points) of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.

It is important to recognize that the eligibility changes we have analyzed are the result of an effort to expand pathways to affordable coverage for all Americans. Churning has often been used to describe the negative outcome of moving into and out of insurance coverage and becoming uninsured. In contrast, we are discussing changes that are a by-product of a system that allows for transitions among insurance pathways. These transitions increase the risks of disrupting care continuity and of having short gaps in coverage. But they represent a different (and less problematic) form of churning than that between having Medicaid or Marketplace coverage and being uninsured.

However, when low-income adults in states that opt not to expand their Medicaid programs experience a loss of income that drops them below 100 percent of poverty, most will not be eligible for subsidized coverage in the Marketplace or for Medicaid. Most nonexpansion states restrict Medicaid eligibility for adults to pregnant women, certain low-income adults with disabilities, and parents of minor children with incomes of no more than 35 percent of poverty on average. In other words, most adults who lose Marketplace subsidies in nonexpanding states will become uninsured, as has traditionally happened to adults who lose Medicaid eligibility.

Policy Implications

A number of policies have recently been proposed to mitigate the effects of churning between Medicaid and Marketplace coverage, and state policy makers should consider them in the light of our findings.

One option is for states to adopt twelve-month continuous eligibility periods in Medicaid as a means of overcoming the churning effects of periodic income fluctuations

A second, more incremental option offered in CMS’s 2012 regulations allows states to assess people’s ongoing eligibility for Medicaid using projected annual income instead of current monthly income.

A third option for states is to use Medicaid funds to purchase coverage in qualified health plans in the Marketplace for people with incomes below 138 percent of poverty.

A fourth approach is the Basic Health Program, an option under the ACA that enables states to combine their Medicaid expansions with Marketplace subsidies into a single program for individuals and families with incomes of up to 200 percent of poverty.

A fifth option relates to how and when income changes are verified.

Finally, a state option that combines enrollment and marketing strategies is to encourage certified Medicaid managed care plans to enter state Marketplaces.

http://content.healthaffairs.org/content/early/2014/03/10/hlthaff.2013.1023.abstract

Comment:

By Don McCanne

The Affordable Care Act (ACA) compounded and locked into place our highly fragmented, multi-payer method of financing health care. It is a system that makes churning inevitable – moving in and out of various plans or having no coverage at all, simply because program eligibility varies depending on each individual’s circumstances which often are in an intermittent state of flux.

As if there was not already enough instability with employer-sponsored and individual market plans, this study shows that under the two major expansions of ACA, “approximately half of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.” Half in just the first year alone. What after that?

Eligibility change is highly disruptive to care. It changes the amounts that the individual or family will have to pay for premiums, cost sharing, and non-covered services. It changes the provider networks that vary under different plans. It can disrupt treatment programs. It can result in gaps in coverage or no coverage at all. As is typical with Medicaid, it can even change the willingness of physicians to accept the individual or family as patients.

And that line about keeping the coverage you have if you want it? Within one year, half will have a change in their eligibility. And the recommendations of the authors will only tweak the instability, but the fundamental problem will not be corrected. It is the ACA model that is irreparably flawed.

Unless we change our model of financing, instability and disruption will be the norm, not only because of shifting eligibility but also because plans obtained through employment or in the market are undergoing dramatic changes – even if less transparent – that will impact all of us with greater cost sharing, narrower networks, and other changes that none of us want. Do Americans really accept this mess as our preferred option for health care financing?

Change to a single payer national health program and this all goes away.

Half will have change of eligibility for Medicaid or subsidies within one year

Medicaid And Marketplace Eligibility Changes Will Occur Often In All States; Policy Options Can Ease Impact

By Benjamin D. Sommers, John A. Graves, Katherine Swartz and Sara Rosenbaum

Health Affairs, April 2014 (online March 12, 2014)

Beginning January 1, 2014, the Affordable Care Act (ACA) established two pathways to health insurance for nonelderly US citizens and legal residents. The first was an expansion of Medicaid coverage for people with annual incomes of up to 138 percent of the federal poverty level in states that elected to expand their programs. The second pathway was subsidizing private coverage purchased via health insurance Marketplaces for people with incomes of 138–400 percent of poverty who do not have an offer of affordable coverage through an employer. The pathways are designed to work in tandem, but a major challenge is how to promote continuity of coverage and health care for people when their incomes and life circumstances cause them to transition between Medicaid and subsidized private coverage.

In states that opt out of the ACA’s Medicaid expansion, changes in income or family circumstance will lead many people to lose coverage entirely unless they qualify for coverage under one of the traditional categories of Medicaid eligibility: pregnancy, disability, or being the impoverished parent of a minor child. A less stark problem that presents a different set of challenges will occur in states that do expand Medicaid: the potential for moving between Medicaid and Marketplace coverage.

Both of these types of “churning”—loss of coverage and frequent transitions in the source of coverage—can cause difficulties. The total loss of coverage raises the most serious problems in terms of access to care, but frequent transitions across coverage pathways also raise important issues for beneficiaries, health plans, providers, and policy makers. From one year to the next or during any given year, many individuals and families will experience changes in eligibility either for Medicaid or for Marketplace coverage. These eligibility changes could lead to both gaps in coverage and disruptions in the continuity of care, because people might have to find new providers or change their existing health treatments if their new insurance plan uses a different provider network or covers different services than their old plan did.

Previous research has estimated that approximately half of low-income adults might experience a change in income or family circumstances leading them to transition from Medicaid to Marketplace coverage (or vice versa) each year.

From the Discussion

We estimated that approximately half (plus or minus 5 percentage points) of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.

It is important to recognize that the eligibility changes we have analyzed are the result of an effort to expand pathways to affordable coverage for all Americans. Churning has often been used to describe the negative outcome of moving into and out of insurance coverage and becoming uninsured. In contrast, we are discussing changes that are a by-product of a system that allows for transitions among insurance pathways. These transitions increase the risks of disrupting care continuity and of having short gaps in coverage. But they represent a different (and less problematic) form of churning than that between having Medicaid or Marketplace coverage and being uninsured.

However, when low-income adults in states that opt not to expand their Medicaid programs experience a loss of income that drops them below 100 percent of poverty, most will not be eligible for subsidized coverage in the Marketplace or for Medicaid. Most nonexpansion states restrict Medicaid eligibility for adults to pregnant women, certain low-income adults with disabilities, and parents of minor children with incomes of no more than 35 percent of poverty on average. In other words, most adults who lose Marketplace subsidies in nonexpanding states will become uninsured, as has traditionally happened to adults who lose Medicaid eligibility.

Policy Implications

A number of policies have recently been proposed to mitigate the effects of churning between Medicaid and Marketplace coverage, and state policy makers should consider them in the light of our findings.

One option is for states to adopt twelve-month continuous eligibility periods in Medicaid as a means of overcoming the churning effects of periodic income fluctuations

A second, more incremental option offered in CMS’s 2012 regulations allows states to assess people’s ongoing eligibility for Medicaid using projected annual income instead of current monthly income.

A third option for states is to use Medicaid funds to purchase coverage in qualified health plans in the Marketplace for people with incomes below 138 percent of poverty.

A fourth approach is the Basic Health Program, an option under the ACA that enables states to combine their Medicaid expansions with Marketplace subsidies into a single program for individuals and families with incomes of up to 200 percent of poverty.

A fifth option relates to how and when income changes are verified.

Finally, a state option that combines enrollment and marketing strategies is to encourage certified Medicaid managed care plans to enter state Marketplaces.

http://content.healthaffairs.org/content/early/2014/03/10/hlthaff.2013.1…

The Affordable Care Act (ACA) compounded and locked into place our highly fragmented, multi-payer method of financing health care. It is a system that makes churning inevitable – moving in and out of various plans or having no coverage at all, simply because program eligibility varies depending on each individual’s circumstances which often are in an intermittent state of flux.

As if there was not already enough instability with employer-sponsored and individual market plans, this study shows that under the two major expansions of ACA, “approximately half of adults likely to be eligible for Medicaid or subsidized Marketplace coverage will experience an eligibility change within twelve months.” Half in just the first year alone. What after that?

Eligibility change is highly disruptive to care. It changes the amounts that the individual or family will have to pay for premiums, cost sharing, and non-covered services. It changes the provider networks that vary under different plans. It can disrupt treatment programs. It can result in gaps in coverage or no coverage at all. As is typical with Medicaid, it can even change the willingness of physicians to accept the individual or family as patients.

And that line about keeping the coverage you have if you want it? Within one year, half will have a change in their eligibility. And the recommendations of the authors will only tweak the instability, but the fundamental problem will not be corrected. It is the ACA model that is irreparably flawed.

Unless we change our model of financing, instability and disruption will be the norm, not only because of shifting eligibility but also because plans obtained through employment or in the market are undergoing dramatic changes – even if less transparent – that will impact all of us with greater cost sharing, narrower networks, and other changes that none of us want. Do Americans really accept this mess as our preferred option for health care financing?

Change to a single payer national health program and this all goes away.

Senate hearing: Learning from other nations’ health systems

Hearing convened by Sen. Bernie Sanders

On March 11, Sen. Bernie Sanders of Vermont chaired a Senate subcommittee hearing on what the health care system in the United States can learn from other countries, particularly Canada, Taiwan, Denmark and France. The following 6-minute video features the testimony of Dr. Danielle Martin, comparing the U.S. and Canadian systems while dispelling myths about health care in Canada.

For a detailed account of the proceedings, including direct links to the full video and to the individual, written statements presented there, see this Quote of the Day post by Dr. Don McCanne, PNHP’s senior health policy fellow.

A four-minute highlight video of the hearing, including all of the panelists from this extraordinary (and to our knowledge, historically unprecedented) session, is available here.

For how the testimony of the Canadian physician, Dr. Danielle Martin, has been received in Canada, click here.

Senate panel examines health systems in Canada, Taiwan, Denmark and France

By Deborah Schumann, M.D.

WASHINGTON – Sen. Bernie Sanders, I-Vt., chairman of the Senate Subcommittee on Primary Health and Aging of the Health, Education, Labor and Pensions Committee, held a hearing Tuesday to gain insight into the health care systems of four other countries, all of which view health care as a human right and have achieved near-universal coverage and access to care for their citizens. 

The senator opened the session with a comparison of the U.S. system with those of other industrialized nations. He noted the U.S. system is characterized by: 

* Double per-capita spending

* Third-world-like access for many in the U.S.

* Financial barriers and bankruptcy consequences related to health care

* 45,000 deaths/year linked to lack of insurance

* Poor efficiency: U.S. ranked 46th out of 48 countries

* Poor outcomes, e.g. of 34 OECD countries, U.S. is 26th in life expectancy

* Drugs are so expensive that many patients forgo treatment

Ranking subcommittee member Sen. Richard Burr, R-N.C., then weighed in, saying that Obamacare is going in the “wrong direction” and that Americans view it unfavorably. He stated that Medicaid is “unsustainable” and is not accepted by 40 percent of physicians. Furthermore, he stated that premiums in the individual market have risen by 41 percent since Obamacare passed. His proposal for improving the system is to increase “individual choice.”

Then the invited witnesses delivered their testimony. 

Tsung-Mei Cheng, L.L.B., M.A., health policy analyst at the Woodrow Wilson School of Public and International Affairs at Princeton University, summarized the features of a single-payer health care system: 

* Single payer does not equal socialized medicine

* Equity of access; access not based on ability to pay

* Equity of payment to providers

* Financing based on ability to pay

* Competition based on quality, not price

* Patients have choice of providers

* No job-lock; not based on employment

* Total spending is easy to control

* Electronic billing leads to substantial savings

* Data capture is facilitated

* Public satisfaction is generally high as demonstrated in other countries

* Medicare (the U.S. single-payer program) is popular

France 

Victor Rodwin, Ph.D., M.P.H., professor of health policy and management at the Robert F. Wagner School of Public Service at New York University, spoke about the French system. It is not a socialized medicine system like Cuba or the U.K., but rather a publicly financed, privately delivered system with supplementary private insurance to cover co-pays. Patients have free choice of providers whether in public or private hospitals. The French people are proud of their system which is based on liberté, égalité and fraternité. There are no gatekeepers or networks and everyone has access to care. The French rate of “avoidable mortality” [e.g. infant and maternal mortality is 55-60 percent that of the U.S., according to The Commonwealth Fund, 2012] France controls its costs through bulk purchasing, price controls and low administration costs. 

Taiwan

Ching-Chuan Yeh, M.D., former Taiwanese minister of health and currently professor at Tzu-Chi University in Taiwan, said that “having a single-payer system is the main reason for our efficient services and also controls prices.” With a national fee schedule, providers compete on the basis of quality. Like France, Taiwan has public financing and private delivery of care which includes both not-for-profit as well as for-profit centers. All payments are made electronically keeping administrative costs down. Dr. Yeh stated that they have achieved 99.6 percent coverage and that there is not much of a problem of waiting lines for services. The country has seen improvements in both longevity and infant mortality since implementing the system in 1995, and they are on the road to a universal, individualized electronic medical record. 

Denmark

Jakob Kjellberg, M.Sc., professor and program director at the KORA-Danish Institute for Local and Regional Government Research in Copenhagen, described the Danish system as “comprehensive and universal.” Danes choose a GP and get referrals from her or him for specialty care. They have full choice of providers including hospitals. If wait-lines are too long, they have the option of going to private hospitals or out of the country. Overall administrative costs are 4.3 percent [i.e. far less than the U.S. system as a whole, which is 15-30 percent by various estimates, but similar to U.S. Medicare’s percentage].

Canada

Danielle Martin, M.D., M.P.P. , vice president for medical affairs and health system solutions at Women’s College Hospital, Toronto, spoke about Canada’s single-payer system. She emphasized that in spite of some shortcomings (wait-times for elective services), the Canadian people are firmly in favor of Canada’s Medicare. There is zero political will in Canada to move to a market-based, for-profit, fragmented system like we have here. She said even conservative politicians don’t oppose Canada’s Medicare, for fear of committing political suicide. The Canadian system is centrally financed but administered by the provinces. It is based on:

* Equity and medical need

* Central oversight for issues e.g. more primary care training

* Low administrative overhead

Canada achieves better outcomes than the U.S. at two-thirds the per capita cost of the U.S. market system. Urgent care is always available.

Speakers for ‘market-based health care’ 

Sally C. Pipes, CEO of the Pacific Research Institute in San Francisco, and David Hogberg, David Hogberg, Ph.D., health care policy analyst at the National Center for Public Policy Research in Washington, had been invited by Sen. Burr to speak in favor of a market-based health care system such as we have in the U.S. Ms. Pipes testified that she had emigrated from Canada to San Francisco. She told the story of her mother who waited several months in a queue, was finally taken care of but died two weeks later. Her opinion was that the Canadian system “would not be suitable for the U.S.” because she thinks that waiting weeks to see a specialist won’t work here. Her punchlines were that 42,000 Canadians come to the U.S. for care every year and that one Canadian top official came to the U.S. for cardiac surgery. Ms. Pipes made clear that waiting too long is bad for your health. 

Mr. Hogberg spoke in favor of “removing the health care system from control of politicians.” He pointed out that the sick are few in number and not political. In his opinion, “patients overuse health care.” He worried about the fact that “France doesn’t pay for pharmaceuticals that are incrementally better.” He reiterated that French co-insurance picks up out-of-pocket expenses for patients while the government controls 77 percent of health care expenditures. His opinion is that the U.S. should look at other countries’ systems in order to discover what policies to avoid and study other competitive markets like auto insurance, food and clothing.

Sen. Sanders asked Mr. Hogberg if we should get rid of Medicare. He did not answer yes or no, but said it is a “moot point.”

Sen. Sanders asked Dr. Rodwin why U.S. health care spending is so high, especially in light of relatively poor outcomes. The answer is that prices are “much higher because we have no price control.” He added, “The free market system doesn’t exist anywhere in health care.”

Sen. Burr asked Dr. Martin why doctors are exiting the public system in Canada. She replied that he had misunderstood her remarks and “that there are no doctors exiting the public system in Canada.” With regard to excessive wait times in Canada, she said that the country has a commission to address the issue and that “the solution is not to move away from our single-payer system toward a multi-payer system.” She said that having a single payer allows the wait-time commission to appropriately address the issue. “Sometimes it is not about the amount of resources, but on how you organize people,” adding, “And this organization should be based on criteria that benefit everyone, not just those who can afford to pay.”

Several other subcommittee members made comments or asked questions.

Sen. Mike Enzi, R-Wy., opined that “the Affordable Care Act was designed to fail so that we would go to single-payer health care.” But he feels that the debacle of the exchanges has convinced Americans that government can’t succeed in universal health care. He didn’t ask any questions.

Sen. Pat Roberts, R-Kan., asked Dr. Martin about how the Canadian system makes changes, e.g. Can the prime minister make changes? She replied that “the public commitment to our single-payer Medicare system is so strong that for a prime minister of any stripe to try and alter that or undermine it in any way would be political suicide.” Sen. Roberts replied, “I got your message.”

Sen. Sanders followed up by saying, “Canadians understand that a system that guarantees health care for all their people in a cost effective way is the way that they want to stay.”

Sen. Chris Murphy, D-Conn., followed up on the wait-time/convenience discussion with the opinion that convenience does not necessarily equal quality. He said that the other two important aspects of quality are outcomes and cost control. 

There was quite a bit of discussion about pharmaceuticals:

* France, Taiwan and Denmark provide drug coverage in their national health care financing systems

* Canada, according to Dr. Martin, has realized that they made a mistake in not including drug coverage in Canadian Medicare. She said that Canada has an estimated 10 percent non-compliance. [the comparable figure in the U.S. is 25 percent]

* Dr. Cheng believes that high drug costs, partially fueled by R&D of new products, is “pricing people out of the system”

* Both Taiwan and Denmark have out-of-pocket limits on drug spending ($1,000/yr. and $600/yr., respectively.

Dr. Cheng concluded the hearing following up on Sen. Murphy’s remarks and responding to a question from Sen. Burr by saying: “Yes, the United States does fund a whole lot of R&D in pharmaceutical and other device innovations. But in so doing we are helping to make the American health care system that much more expensive; in fact so expensive that we are pricing people out of the health care altogether . … In single-payer systems, the government can set aside money for R&D.” He added: “A very serious issue in U.S. health care is overuse. An Institute of Medicine book states that about one-third of U.S. health care is waste. Unnecessary services are about one-third of that waste.”

A video of the hearing and links to statements of all participants can be found here: http://www.help.senate.gov//hearings/hearing/?id=8acab996-5056-a032-522e… 

A 4-minute YouTube video of clips from the hearing can be viewed here: https://www.youtube.com/watch?v=9WdqtPLRc1A 

Dr. Deborah Schumann practiced ophthalmology for 25 years in a variety of clinical settings. Since retiring from practice she has been an active advocate for reform of the U.S. health care system. She is active in Healthcare-NOW of Maryland as well as Physicians for a National Health Program. She resides in Bethesda, Md.