Doctors: New Health Care Plans Raise Red Flags

By Louise Radnofsky
The Wall Street Journal, November 26, 2013 Physicians groups told Obama administration officials Tuesday that they are worried that new insurance plans under the Affordable Care Act offer only limited networks of providers and low reimbursement rates for doctors, and that could make it difficult for millions of those enrolled to actually get health care. As the Journal has reported, some health plans don’t include big brand-name health providers in their networks and are slashing how much they’ll pay medical practices for treating the newly covered. Representatives from the major physician lobbying groups raised these issues Tuesday in a White House meeting with health officials including Chris Jennings and Jeanne Lambrew of the White House, and Chiquita Brooks-LaSure of the Centers for Medicare & Medicaid Services. “Some of the things were not a surprise to them… they’re acutely aware,” Shawn Martin, a top lobbyist for the American Academy of Family Physicians, said after the noon meeting. The American Medical Association, the American Academy of Family Physicians, American Academy of Pediatrics, and American College of Physicians, the American Osteopathic Association, the American Medical Group Association and the American Association of Nurse Practitioners were among the groups present, participants said. http://blogs.wsj.com/washwire/2013/11/26/doctors-new-health-care-plans-raise-red-flags/

Comment:

By Don McCanne, M.D. The new health plans to be offered in the exchanges are avoiding excessive premium increases by using narrow networks of physicians and by lowering payment rates for health services. The leaders of our nation’s leading organizations of health care professionals are concerned enough about what this might do to patient access that they met with Obama administration officials at the White House. The administration officials were already “acutely aware” of these problems. Of course, they were. They result from fundamental design flaws in the financing model of the Affordable Care Act. The model was designed by and for the private insurance industry. It is likely that members of these professional organizations are not only concerned about the patients, narrow networks and lower payments have a direct effect on their livelihoods. In a well designed system, patients must always come first, but the professionals taking care of the patients should be content as well. Grumpy doctors and nurses detract from an optimal patient care environment. There will be more discontentment as the Obamacare model of high-deductibles, narrow networks, and payment restrictions extend to employer-sponsored private plans. These trends will no doubt expand with the proliferation of private insurance exchanges catering to employers – exchanges outside of the government-operated Obamacare exchanges. Even the private Medicare Advantage plans are being modified in response to their overpayments being pared back. UnitedHealth, the nation’s largest private insurer, has notified thousands of physicians that they are being dropped from their Medicare Advantage network. Do we really want to keep headed in this direction? The traditional Medicare program does not use narrow networks. Patients have their choice of their health care professionals. Medicare payment rates are higher than the rates expected to be offered by most of the exchange plans. It would not take much to improve Medicare, and then it would be an ideal program for covering everyone. You can bet that the representatives of these professional groups didn’t ask for single payer to be put on the table. Too bad.

Health at a Glance 2013 – OECD Indicators

OECD, November 21, 2013

Editorial: From expenditure growth to productivity growth in the health sector

By Stefano Scarpetta, Director for Employment, Labour and Social Affairs Almost six years since the start of the global financial and economic crisis, economic conditions vary widely across OECD countries, with the United States, Canada and Japan on a path to recovery, while the economic prospects of many European countries remain subdued. After a period in which, as part of the stimulus packages, greater resources were channelled to welfare and social protection programmes, the shift towards restoring sound fiscal conditions has often implied substantial cuts in public spending. Like other government programmes, health care has been the target of spending cuts in many OECD countries. The crisis has had a profound impact on the lives of citizens across the world, and has tested the resilience of many families as they see their wealth and incomes decline. Millions of people have joined the ranks of the unemployed and millions more are experiencing financial stress. The combined effects of the crisis with the associated recent expenditure cuts as well as health care reforms have led to uncertainty about the impact on the health and well-being of the population. The most recent OECD health statistics, presented in this edition of Health at a Glance, provide a comprehensive picture of how health systems have evolved during the crisis and the challenges which lie ahead. Growth in health spending has slowed markedly in almost all OECD countries since 2008. After years of continuous growth of over 4% per annum, average health spending across the OECD grew at only 0.2% between 2009 and 2011. Total health spending fell in 11 out of the 34 OECD countries between 2009 and 2011, compared to pre-crisis levels. Not surprisingly, the countries hit hardest by the economic crisis have witnessed the biggest cuts in health expenditure growth. In order to limit or reduce public health expenditures, countries have worked to lower the prices paid for publicly financed health care, including cutting the price of medical goods, particularly pharmaceuticals. Governments have targeted hospital spending through budgetary restrictions and cuts to wages. Several countries including Greece, Ireland, Iceland and Estonia have reduced nursing wages in response to the crisis as well as those of salaried GPs. Expenditure on prevention and public health has also been cut since 2009. Further, in several OECD countries, patients are now expected to assume a greater share of health costs. There is evidence that more people in countries such as Greece and Italy are foregoing medical care due to financial constraints, reflecting reduced household incomes, but also perhaps rising out-of-pocket costs. Low-income groups are the worst affected, although they are likely to have the highest health care needs, and they may be foregoing necessary care such as medicines or routine medical check-ups for chronic conditions. This may have long-term health and economic consequences for the most vulnerable groups in society. Many of the reforms implemented since the start of the crisis have had an immediate impact on public expenditure. Some have been controversial, with considerable unrest and political pressure from industry groups, and some may also have had undesirable consequences for access, outcomes and equity. For example, greater out-of-pocket costs are likely to reduce health care use among those in highest need, leading to greater inequity and inefficiency over the longer term. In the new, more constrained, fiscal climate, the challenge for health care policy makers is to preserve quality health care coverage for the whole population while converting a system built on notions of unconstrained growth to one that is based on greater productivity and fiscal sustainability. This challenge is not new. Countries have pursued the twin objectives of efficiency and equity in health for decades. The economic crisis means that health care policy makers must swiftly and convincingly adopt a health care productivity agenda. Health at a Glance 2013 – OECD Indicators (213 pages): http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf

Comment:

By Don McCanne, M.D The 2013 edition of OECD’s “Health at a Glance,” in text, graphs and tables, provides updates of international comparisons of indicators of health and health systems. The graphs are likely familiar to many of you. This report is worth downloading just to have the updates. The editorial discusses the stresses on health systems resulting from the Great Recession, and the government responses to those stresses. A trend that should alarm us all is that “patients are now expected to assume a greater share of health costs.” Further, more people are forgoing medical care due to financial constraints. There is concern that the responses may be having undesirable consequences for access, outcomes and equity. The editorialist emphasizes that nations should pursue the objectives of efficiency and equity by adopting a new health care productivity agenda. Improving productivity is fine, but for the United States, it is imperative that we immediately adopt a financing infrastructure that ensures equity. All other OECD nations are light years ahead of us on that.

Obamacare Debate: Flowers vs. Baker

The Real News, October 1, 2013 JESSICA DESVARIEUX, TRNN PRODUCER:  With us to discuss the Affordable Care Act are Dean Baker and Dr. Margaret Flowers. Dr. Flowers joins us in-studio. She’s a pediatrician in the Baltimore area and the Maryland chapter of Physicians for a National Health Program cochair, and she’s the secretary of health for the Green Shadow Cabinet… And joining us from Washington, D.C., is Dean Baker. He’s the codirector of the Center for Economic and Policy Research. DEAN BAKER, CODIRECTOR, CEPR:  There’s lots of grounds for criticizing the ACA. But this is a huge step forward. We’re going to have tens of millions of people that will be able to get insurance who haven’t had it previously. And, again, for the 100-plus million who are now insured, they will actually have real insurance, because if they do get sick, lose their job, they’ll still in most cases be able to get affordable insurance through the exchanges. So I have to see that as a big step forward. DESVARIEUX: Okay. Let’s have Dr. Flowers respond to that. Do you see that as a step forward? DR. MARGARET FLOWERS, COCHAIR, PNHP:  No, I actually see the Affordable Care Act as a step backwards. It takes us farther in the direction of privatized health care. And the way that we really need to go is towards greater–a publicly financed universal health care system. That’s the most efficient and most equitable way to provide health care… BAKER: Well, it’d be great to have, you know, universal Medicare, but that wasn’t about to be coming. So basically our choice is having health care provided through private insurers or not having it at all. And the fact is, we have 100-plus million people who get most of their health care through private insurers now. And yeah, they do lots of bad things, but the alternative is not getting it all. So I can’t somehow tell people they’re better off not getting health care than having it provided through private insurers, as much as I may not like them. DESVARIEUX: But is that true? Is that really the alternative? We only have two choices here? FLOWERS: No. And, actually, during the health reform debate, a point that we were making, especially towards the end when it looked like the Affordable Care Act was going to go through, was don’t give hundreds of millions of dollars in subsidies to private insurance companies where they’re going to hang on to a lot of that and still deny people care. We should be giving that to our public programs to expand them more and really shift us in the direction we need to go, towards a greater publicly financed health care system. Part of the reason that the Affordable Care Act went through is that it wasn’t challenged by people on the left, by people that supported single-payer. People were told, well, this is all that we can get, and so they accepted that. http://therealnews.com/t2/index.php?option=com_content&task=view&id=31&Itemid=74&jumival=10805

The Single-Payer Alternative

By Nancy Folbre
The New York Times, November 25, 2013 Rush Limbaugh’s take on the disastrous rollout of the Affordable Care Act could, ironically, warm the hearts of those at the other end of the political spectrum. He contends that President Obama knew all along that the Affordable Care Act would crash and burn, but pushed it through so that the conflagration would clear the way for single-payer health insurance. Yet one of the greatest advantages of a single-payer system — its relatively low administrative costs — has been thrown into sharp relief by problems registering with the new health exchanges. In theory, competition and choice should increase efficiency. In practice, health insurance companies are able to take advantage of the complexity and uncertainty surrounding health care choices to make comparison shopping very difficult. The process of negotiating relationships with new health care providers because old ones are “out of network” is physically and emotionally exhausting. Insurance companies benefit from promoting policies that are difficult to understand and make consumers fearful of any change in their coverage. David Himmelstein and Steffie Woolhandler, co-founders of Physicians for a National Health Program, regularly assert that elimination of the huge paperwork and overhead imposed by private insurance companies could save enough to cover the estimated 31 million of Americans who will remain uninsured under the Affordable Care Act. My fellow Economix blogger Uwe E. Reinhardt, expanding on this theme, notes that the Institute of Medicine of the National Academy of Sciences recently estimated excess administrative costs of $191 billion, again more than enough to attain truly universal health care coverage. Most such estimates are limited to the monetary costs incurred by insurers, doctors and hospitals and don’t include the value of the time that health care consumers must devote to managing a torrent of inscrutable paperwork that can become truly frightening for the critically ill. A single-payer insurance system, whether based on an extension of Medicare or on the Canadian model, promises many profoundly important benefits. Right off the mark, it promises simplicity. No wonder conservative pundits are afraid of it. (Nancy Folbre is professor emerita of economics at the University of Massachusetts, Amherst.) http://economix.blogs.nytimes.com/2013/11/25/the-single-payer-alternative/

Comment:

By Don McCanne, M.D. Experts across the political spectrum have long understood how much more effective a single payer system would be in achieving our goals of universality, comprehensiveness and affordability than is our current financing infrastructure that was left in place by the Affordable Care Act. When this fact was so obvious at the time reform was being crafted, even to President Obama, then why did we reject single payer in favor of our highly flawed system? It was the progressive community, of all people, that took it off of the table. The words of Dean Baker echo the prevailing view of many progressives at that time: “Well, it’d be great to have, you know, universal Medicare, but that wasn’t about to be coming. So basically our choice is having health care provided through private insurers or not having it at all.” So the view was, single payer is the system that will work for us, so let’s choose between expanding our current dysfunctional system of private insurers or let’s have nothing at all. Talk about a non sequitur! Two developments stem from this unwise choice in reform, both related to how unsatisfactory the policies are – costly but all too ineffective. On the one hand, the conservatives opposed to any effective reform are telling us that things are in such a mess that we will have to resort to single payer to bail us out. On the other hand, many progressives, like Professor Nancy Folbre, are now motivated to speak up in favor of single payer since the Affordable Care Act clearly is going to fall intolerably short of our goals. Most moderates and even some conservatives understand the imperative of single payer. The point is that now is the time to talk about single payer, with a loud and clear voice. As the deficiencies in the Affordable Care Act become ever more obvious to the public at large, they need to know that there is a way out. Let’s hear it, loud and clear now: We should have gone for single payer… and we still can!

Too little, too late on “You can keep it”

By Trudy Lieberman
Columbia Journalism Review, October 31, 2013 I have a question for all the reporters busy asking whether Obama misled Americans with his oft-repeated line that “if you like your health plan, you can keep it”: Where have you been? You should have challenged this claim well before now. You should have been reporting that some people in the individual insurance market might receive cancellation letters … well before it started happening to them…. http://www.cjr.org/the_second_opinion/reporting_too_little_too_late_on_obamas_you_can_keep_it.php?page=all

The origins of, “If you like your health insurance you can keep it”

By Richard Kirsch
Huffington Post, November 1, 2013 There are good reasons why President Obama’s leading message on health care during the 2008 campaign … was “if you like your health insurance, you can keep it.” That message was created to overcome the fear-mongering that had blocked legislative efforts to make health care a government-guaranteed right in the United States for a century…. As one of the people who engaged early on in building the effort that led to the passage of the Affordable Care Act, I am keenly aware of this history. … As we predicted, the opponents of reform used fear-mongering … to try to kill the Affordable Care Act…. The opponents of reform have used reckless, baseless charges to try to kill reform. I’m glad that President Obama used a slight exaggeration to finally provide secure health coverage for all Americans. http://www.huffingtonpost.com/richard-kirsch/the-origins-of-if-you-lik_b_4190922.html

Comment:

By Kip Sullivan As Trudy Lieberman noted in her article for Columbia Journalism Review, and as some noted as early as 2008 (1), it has been known for a long time that millions of Americans would not be able to keep their health insurance under the Affordable Care Act. Yet President Obama and many other proponents of the ACA claimed this would not happen. They said people who liked their health insurance could keep it. If Obama et al. had made this claim once or twice in the heat of a debate, few would be questioning their integrity now. But they made this claim repeatedly, both before and after the ACA was enacted. The chickens are coming home to roost. Obama and other Democrats are taking a terrible beating for having made a promise they knew or should have known they couldn’t keep. What explains such irrational behavior? In his essay for the Huffington Post, Richard Kirsch takes a stab at an answer. Kirsch is in an ideal position to give us one. He was present at the creation of the marketing strategy that was supposed to neutralize the inevitable attacks on the ACA from the right. Kirsch was the chairman of the “health policy refinement committee” of the Herndon Alliance, a coalition formed in 2005 to promote whatever it was the Democrats decided to put forward in the name of “health care reform,” and he later became the campaign director for Health Care for America Now, the leading organization in the fight to enact whatever it was the Democrats decided they could get through Congress. Kirsch tells us the mantra was invented to “overcome … fear-mongering” that he and the entire rest of the world predicted conservatives would use to stop the ACA. But this argument merely begs another question: Why would the public be reassured by an argument that was so easily rebutted, at first by commonsense and eventually by reality as well? Why wasn’t it obvious to Kirsch et al. that inaccurate statements would come back to haunt the makers of those statements? The answer can be found in the “framing” and “messaging” craze that erupted late in 2004 after John Kerry lost to George Bush.(2) George Lakoff and other “framing” gurus claimed that conservatives were winning elections liberals should have won because conservatives were “messaging” better than liberals. More specifically, the argument was that voters respond to emotions, not “facts,” and if voters and conservatives don’t care about facts, liberals shouldn’t either. Instead, liberals should convene focus groups and conduct polls to determine what buzzwords and claims “resonate” with voters’ emotions – their “frames” – and use those buzzwords and make those claims. In this comment I don’t propose to take sides on whether Lakoff and other “framing” proponents were promoting science or pseudoscience. I do argue that “framing” theology was easily interpreted as an excuse to say anything regardless of the evidence, regardless of whether a proposal or legislation actually existed, and, after legislation had been introduced, regardless of the actual language in that legislation. I argue that that’s what happened to Kirsch, the Herndon Alliance, and other advocates of the ACA. Consider this memo published by the Herndon Alliance and others in June 2008.(3) The memo urged advocates of “health care reform” to claim that “reform” (“reform” was not explained) would: •  guarantee “choice among plans,”
•  guarantee that Americans could “keep our current doctor,”
•  “make insurance companies compete to keep costs down and quality up,”
•  stop insurance companies from “overriding doctors’ decisions about what their patients need,” 
•  keep “deductibles low,” and
•  save “billions by cutting administrative waste and moving to electronic medical records.” The memo made no attempt to document the truthfulness of these claims. That is not surprising, because not one of these claims was accurate then, and not one is accurate now. So how did the Herndon Alliance et al. justify urging advocates to make these claims? They cited “framing” theology. They said these claims had been “market-tested” on focus groups and “online dial groups” of “swing voters” to determine what “frames” lurked in the minds of the participants and what “messages” were consistent with those “frames.” In short, the Herndon Alliance et al. convinced themselves that misrepresentation is moral and effective if the misrepresentation has been shown to elicit positive responses in focus groups and surveys. Several factors contributed to the widespread acceptance of this flimsy rationale for inaccuracy among the leaders of the pro-ACA movement. One was the failure of the media to question the buzzwords and claims concocted by the Herndon Alliance and promoted by HCAN and eventually Obama and members of Congress. Trudy Lieberman criticized the media for this failure even before the ACA was enacted. In a 2009 article she called the Herndon Alliance’s buzzwords “hollow as straw” and “Orwellian” and recommended that reporters “avoid quoting someone who uses those words unless they have something more significant to say.”(4) But the media did not do that, and the Herndon Alliance’s claims quickly mutated into conventional groupthink among leaders of the pro-ACA movement. To those leaders and members of Congress who could have warned Democrats not to repeat “if you like your health insurance etc.” and now lament the fallout from the constant repetition of that canard, I repeat Ms. Lieberman’s question: Where have you been? (1) https://pnhp.org/blog/2013/11/08/editorial-who-first-said-you-can-keep-the-insurance-you-have (2) http://www.nytimes.com/2005/07/17/magazine/17DEMOCRATS.html?pagewanted=all&_r=0G (3) http://familiesusa2.org/assets/pdfs/drew-and-celinda-short-memo-revised-6-11-08.pdf (4) http://www.cjr.org/campaign_desk/what_journalists_can_learn_fro_1.php?page=all