PNHP

Reasons for Outrage on Health Care

Reasons for Outrage on Health Care

By Laura S. Boylan, M.D.
The New York Times, Letters, July 9, 2013

Re “Diagnosis: Insufficient Outrage,” by H. Gilbert Welch (Op-Ed, July 5):

As medical “cost sharing” (read: “cost shifting”) grows, hidden costs will be revealed, and outrage, already simmering, can be counted on coming to a boil. We need to stop pretending that the rules of the market will provide us with high-quality, high-value health care and join the rest of the developed world with universal health insurance.

Medicare’s 48th birthday is coming up this month. Let’s expand and improve on this most successful and popular of American institutions with publicly financed and privately delivered single-payer health care for all.

The writer is a clinical associate professor of neurology at New York University School of Medicine.

Burdened by insurance paperwork

By Melvin W. Young, M.D.

 We doctors should “rage” against a system so perverse that on any given day a physician may treat 15 patients with as many insurance plans requiring unproductive paperwork. It is a system so perverse that it forces us to hire clerks whose only role is to seek authorization for needed procedures.

It is a system so skewed against us that a letter from a lawyer sets our hearts racing. A system so out of control that chief executives of major insurance companies make salaries in the millions of dollars as we doctors struggle to meet payroll and pay the rent.

The excesses in the system may justifiably lead to outrage, but we doctors are likewise outraged at the blame heaped upon us for a failed system not of our creation.

The writer is a cardiologist. He lives in Dover, Vt.

http://www.nytimes.com/2013/07/10/opinion/reasons-for-outrage-on-health-care.html?_r=0

First do no financial harm

First, Do No (Financial) Harm

By Christopher Moriates, MD; Neel T. Shah, MD, MPP; Vineet M. Arora, MD, MAPP
JAMA, July 8, 2013

“First, do no harm” is a well-established mantra of the medical profession, but it may need to be reconceptualized in an era of unsustainable health care spending. Medical bills are now a leading cause of financial harm and physicians decide what goes on the bill. The possible consequential harm is substantial, often leading to lost homes and depleted savings. While the Affordable Care Act will ensure expanded coverage, newly insured Americans will not necessarily be immune from increased costs of their care. More Americans than ever before are enrolled in high-deductible insurance plans, meaning that seemingly simple decisions that physicians make about testing could directly lead to thousands of dollars in out-of-pocket costs. This strain on household budgets can cause further erosion of personal health.

Just as physicians play an important role in preventing serious infections, physicians can also help patients avoid experiencing financial harm as a result of medical care.

SCREEN FOR FINANCIAL HARM

First, physicians can help patients avoid financial harm by screening each patient to determine financial risk and preferences.

ADOPT A UNIVERSAL APPROACH

In 2007, the majority of medical debtors had health insurance at the beginning of their illness, and an estimated 25 million Americans were underinsured. Hence, it is increasingly difficult to know which patients will be faced with insurmountable medical bills in the near future. Since physicians cannot be sure which patients will ultimately have unaffordable medical bills, they should treat all patients as if they could be.

This approach applies to both inpatient and outpatient encounters because patients often face significant financial obligations in both settings. Although physicians may assume that hospitalizations for insured patients are automatically covered by health plans, in reality these patients may still face large co-payments. Thus, in some instances whether hospitalization can be avoided should be discussed. In addition, the payer may refute the appropriateness of admission or leave coverage gaps due to high deductibles, caps, or other cost-sharing mechanisms. In the ambulatory care setting, patients may pay a percentage of the fees for services.

UNDERSTAND FINANCIAL RAMIFICATIONS AND VALUE OF RECOMMENDATIONS

Many studies demonstrate that physicians are unaware of the cost of routinely ordered tests, let alone the potential financial risks for patients seeking care. To explain potential options and their fiscal implications to patients, physicians will need to take responsibility for knowing the financial ramifications of the care they are providing.

OPTIMIZE CARE PLANS FOR INDIVIDUAL PATIENTS

Physicians also should learn how to optimize personalized health care decisions for patients’ financial health.

CONCLUSIONS

Financial concerns are important to patients and physicians need to be prepared to address this aspect of their care. Although these financial discussions may present some challenges, physicians already participate in difficult discussions with patients about opiate abuse, domestic violence, and end-of-life decisions. To provide truly patient-centered care, physicians can live up to the mantra of “First, do no harm” by not only caring for their patients’ health, but also for their financial well-being.

For the full JAMA article (free access):
http://jama.jamanetwork.com/article.aspx?articleID=1709839

Comment:

By Don McCanne, M.D.

In these days of outrageous health care costs physicians now have not only the obligation to provide care as close to optimal as the circumstances will allow, they also have an obligation to prevent personal financial harm to the patient that could result from their medical decisions. But should the latter really be the physicians’ obligation?

The authors of this JAMA article list steps to be followed during patient encounters designed to prevent financial harm to patients. Doesn’t the physician already have enough to do without having to become the keeper of the patients’ pocketbooks? Unfortunately, under our current dysfunctional system of financing health care, too many patients face significant financial barriers to care. The physician remains the person in charge of determining the magnitude of those barriers, simply based on the medical management selected.

The Affordable Care Act will not help much since the new standard for private insurance is low actuarial value, high-deductible plans. In fact, the financial barriers will become more commonplace as employers are now greatly expanding the use of consumer-driven, high-deductible plans.

Patients who previously weren’t concerned much about their out-of-pocket costs are now going to want more information from physicians about what their own plans will or will not cover, how much they will have to pay out-of-pocket, whether the specialists or diagnostic facilities are in or out of their networks, which prescriptions are covered and under what tier, and many other spending issues for which the physicians frequently do not have the answers. Yet knowing the answers is now becoming the responsibility of physicians?

Why do we have a system with so much financial exposure to patients when other nations have much lower national health expenditures with cost sharing usually at negligible levels? It is because of the nutty idea that only patients can control costs when they have to pay out-of-pocket (consumer-driven health care), when we know that is absolutely untrue. Other nations have proven that there are far more effective methods of controlling costs that not only provide financial security for the patients, but also improve the allocation of health care dollars, providing higher quality and greater value.

Physicians should be leading the bandwagon in first doing no financial harm by supporting a system that totally separates financing from the clinical environment. If they could convince the nation that we need a single payer national health program then they could proceed with tending to patients’ health care needs while letting our own public administrators deal with the financing of the system.

Financial barriers harm patients. It is our obligation to first do no harm by removing those barriers – for everyone. Then we can get on with simply taking care of the patients.

Night terrors of the uninsured

For all of the promise of the Affordable Care Act, it has holes.

By Diana Wagman
Los Angeles Times, July 6, 2013

It’s 3:14 a.m.

I’m awake. Every night for the last six months, my eyes have opened just after 3. It’s my personal witching hour when my demons come out of the closet and surround the bed whispering messages of doom. My husband sleeps on, oblivious. I’ve developed some tricks to keep the creatures at bay. I count backward, I count my blessings, I recite what little poetry I know by heart. If I start listening to the goblins, that’s it, I’m up for the duration.

What am I worried about? I have smart, healthy children, one college graduate and one in college. I have a house and a husband and a car. What I don’t have is a job. And because I’m unemployed, we don’t have job-based health insurance. My husband works hard. He works a lot. But he’s always been freelance, and he’s hardly ever had insurance. That’s what I get from my kind of work, teaching at the university level — never much in the way of salary, but benefits. Now the work has dried up and I’m benefit-less again.

I had a great one-year appointment teaching at a California State, with wonderful colleagues and interesting students. When the school decided to make the job a permanent position, I couldn’t apply. I didn’t have the required advanced degree. Twenty years working in my field, four published books and many published articles and stories, and I wasn’t eligible to continue doing exactly what I’d been doing. I know it has to do with the school’s accreditation. My department would have kept me if it could, but it couldn’t. I looked into getting that advanced degree and was even accepted at a school nearby, but I wouldn’t have been able to have the degree “in hand” by the time the permanent job started this fall.

So I’m out of work. Again. And because healthcare in this country is tied to employment, we are out of luck. Again. I had cancer. My daughter was hit by a car and got a concussion and a fractured ankle. I know bad things can happen to me, to my family. We have to have health insurance. And we have to pay for it ourselves. And that keeps me up at night.

I was excited when the Affordable Care Act was introduced. I thought it was about time everybody in this country had insurance. I believed it was ridiculous that we’re the only wealthy, Western nation without universal care. But the Affordable Care Act is not universal care. It’s not the single-payer system I so hoped for. It’s a step in the right direction, but for people like my husband and me, who make a pretty good income, it’s unlikely to give us any kind of break. We’ll still have to pay for our insurance entirely ourselves, and I’m not optimistic the price will go down.

Thanks to the Affordable Care Act, my new insurance company can’t deny me because I had cancer. Unfortunately, at least until January, when additional provisions of the law go into effect, they can charge me for it. For my family of four, to get care comparable to what I had through the CSU, we will spend $1,500 a month, or $18,000 a year. That’s a lot of money. I have to teach a lot to make that. The insurance through my former job was fantastic. We could choose our doctors, our co-pay was low and our deductible very reasonable.

We had that same insurance when I was diagnosed with cancer. Back then I was working at a different Cal State school and thank God I was. Without insurance, we would have lost our house, decimated the college funds, spent every bit of savings we had, and, six years later, I’m sure we’d still be paying off those bills. Or we would have gone bankrupt. Some 700,000 Americans every year declare bankruptcy because of medical bills. The number in Japan? Zero. The number in Germany? Zero.

I was lucky my cancer diagnosis came when it did. I had a job and I kept it until a year after treatment, when, due to budget cuts to the CSU system, I was laid off. We went on COBRA, because no other insurance would have me — the cancer survivor — until this latest job came along. COBRA is even more expensive now.

“Do something else,” the demons whisper. I have poured over Craigslist looking for different kinds of work. I recently applied to be an animal control officer — no lie — but withdrew my application when I read the blog, “A day in the life of an animal control officer.” Too sad, too confrontational, too many pit bulls for me. And really, I love teaching. It’s what I have done for 20 years.

“Go back to school,” other demons — and my husband — sometimes say, but it’s expensive, we’re already paying my daughter’s college tuition, and I’m in my 50s. Who’s going to hire me as a full-time teacher for a permanent position when I’d be eligible to retire in less than 10 years? And if some school does hire me two years from now, will I work long enough to pay back my college loans?

I could hobble along, teaching where I can, doing some independent work, and my income would pay my daughter’s tuition or at least her living expenses, if it wasn’t for our health insurance. The Affordable Care Act mandates I have it, and I know my family needs it, but paying for it means other things will suffer. We’re not poor, I don’t want to suggest that we are, but we will have to make some hard choices if I’m not working and we’re paying $1,300 a month to an insurance company.

I had hoped that, under the new healthcare system, essential services for everybody would be covered by the government, as they are in every other First World country. At the very least I wanted the Affordable Care Act to be what it says it is: affordable care for everybody.

That said, I’m glad that an insurance provider can no longer deny me for having had cancer and that our unemployed son can stay on our insurance until he’s 26. By then, I tell myself, surely he will have a full-time job.

“But will his job have benefits?” Those are my 3 a.m. demons hissing at me again. And I have no answer for them.

Diana Wagman’s most recent novel is “The Care and Feeding of Exotic Pets.”

Latest handout to big insurers hurts Medicare

Instead of attacking Medicare, we should be expanding it to all

By Johnathon Ross, M.D.
The Blade (Toledo, Ohio), July 4, 2013

Medicare’s costs will jump by $7.43 billion next year because of an unprecedented decision by the federal government to change payment rates for private, for-profit Medicare Advantage plans.

The government’s action will result in a huge financial windfall for big health insurers, whose Washington lobbyists pushed hard for the new rates.

Enrollment in privately run Medicare Advantage plans, which cover 13.1 million beneficiaries, was expected to dip sharply over the next few years, because of a planned reduction in government overpayments to these plans.

Studies by the Government Accountability Office and many private groups repeatedly have drawn attention to these overpayments. These studies suggest that if the 13.1 million beneficiaries were enrolled in the traditional Medicare program, their costs of care would have been 14 percent lower than the payments made to the private plans, with no loss in the quality of care.

The overpayments occur because private Medicare Advantage plans tend to enroll healthier, less-costly seniors, yet they receive a larger average payment per enrollee from the government.

The Affordable Care Act also acknowledged these overpayments. Yet the secretary of health and human services, Kathleen Sebelius, has announced that a scheduled 2.2 percent reduction in payments to the for-profit plans this year will now become a 3.3 percent increase instead.

The extraordinary rate-setting directive from Ms. Sebelius to the Centers for Medicare and Medicaid Services (CMS), which spurned historical practice and the advice of the CMS actuary, will result in an obscene windfall for the private, for-profit insurers.

This announcement, leaked shortly before the stock market closed, caused stock prices for the nation’s five largest for-profit health insurers to surge over the next week. That yielded an instant $13.2 billion bonanza for investors.

UnitedHealth reaped the largest windfall. Based on its share of the market, UnitedHealth will receive an extra $1.49 billion from Medicare for its Medicare Advantage plans in 2014, and $14.3 billion to $20.9 billion over the next decade, triggering a $5.04 billion surge in the value of UnitedHealth’s stock.

Other plans saw similar gains. But taxpayers will foot the bill.

It is hard to fathom how we can allow this massive payout to private insurers, when some in Congress are proposing higher premiums, higher out-of-pocket payments, and even vouchers to undermine traditional Medicare, instead of shoring it up. These bonus payments to the privately run plans will further divert resources from the more efficient traditional Medicare program.

Instead of attacking Medicare, we should be improving it and expanding it to all. The traditional Medicare program has worked for more than 50 years to cover our most vulnerable disabled friends, neighbors, parents, and grandparents.

Medicare came into existence because the private insurance industry would not cover seniors and disabled people. Being old and disabled are pre-existing conditions. Medicare would be an excellent model for providing health care to all, and superior to the Affordable Care Act.

The Affordable Care Act will cover only half of the 50 million uninsured Americans. It will cost an extra $100 billion a year, because it builds on a “sickness care” system run by wasteful private insurance companies. Thanks to those companies, our health care is saddled with about $400 billion a year in unnecessary bureaucracy and paperwork.

Studies suggest that by replacing costly private insurers with a streamlined nonprofit agency that pays all medical bills, similar to how Medicare operates today, we could cover everyone and upgrade existing coverage at no added cost.

Research consistently has shown that for-profit health care and insurance produces worse outcomes at higher prices. When will we conclude that health care is a basic human need and provide it to all our fellow citizens, just as we together support education, police, and fire and rescue services?

Expanding Medicare to all Americans would save lives and money. It is the right thing to do.

Dr. Johnathon Ross of Ottawa Hills is past president of Physicians for a National Health Program, which supports single-payer national health insurance.

http://www.toledoblade.com/Opinion/2013/07/04/Latest-handout-to-big-insurers-hurts-Medicare.html

Why physicians must reclaim their profession

By Andrew D. Coates, M.D., F.A.C.P.

The 10-minute YouTube video found after the jump shows Dr. Andrew Coates of upstate New York, president of Physicians for a National Health Program, speaking at a program organized by Maryland’s Healthcare is a Human Right Campaign in Columbia, Md., on June 27.

Excerpt: “We need to claim our proper place in society and part of doing that is advocating for a national health program, nothing less than something that will provide comprehensive care for absolutely everyone.”

Watch Dr. Coates on restoring integrity and justice to the medical profession by fighting for universal health care, and hear his thoughts on why doctors can no longer stand for an exclusionary and privatized system.

Insurers game risk against each other

Do Insurers Risk-Select Against Each Other? Evidence from Medicaid and Implications for Health Reform

By Ilyana Kuziemko, Katherine Meckel and Maya Rossin-Slater
National Bureau of Economic Research, Working Paper 19198, July 2013

Abstract

Increasingly in U.S. public insurance programs, the state finances and regulates competing, capitated private health plans but does not itself directly insure beneficiaries through a public fee-for-service (FFS) plan. We develop a simple model of risk-selection in such settings. Capitation incentivizes insurers to retain low-cost clients and thus improve their care relative to high-cost clients, who they prefer would switch to a competitor. We test this prediction using county transitions from FFS Medicaid to capitated Medicaid managed care (MMC) for pregnant women and infants. We first document the large health disparities and corresponding cost differences between blacks and Hispanics (who make up the large majority of Medicaid enrollees in our data), with black births costing nearly double that of Hispanics. Consistent with the model, black-Hispanic infant health disparities widen under MMC (e.g., the black-Hispanic mortality gap grows by 42 percent) and black mothers’ pre-natal care worsens relative to that of Hispanics. Remarkably, black birth rates fall (and abortions rise) significantly after MMC—consistent with mothers reacting to poor care by reducing fertility or plans discouraging births from high-cost groups. Implications for the ACA exchanges are discussed.

From the Introduction

In summary, under MMC, infants whose costs are likely to exceed the capitation payment die more frequently, experience worse health outcomes, receive diminished care, or are not born at all.

From the Conclusion

Introducing risk-adjustment could potentially address the risk-selection results we have presented, though, historically, governments have been reluctant to risk-adjust based on race. Adjusting based on past health conditions is very challenging in the MMC setting and, as previously noted, is rarely attempted. First, plans would have to submit some accounting of their clients’ health conditions to the government, so “intensive” coding becomes a problem, as it is in Medicare Advantage and the Medicare Prospective Payment System. Second, while Medicare can calibrate a risk-adjustment formula by regressing enrollee costs on dummies for past health conditions using cost and claims data from its FFS pool, state governments under MMC typically do not have a public FFS option and thus will not have the cost and claims data that Medicare uses. Third, risk-adjustment formulae typically document existing health conditions using twelve months of pre-data, and use this information to forecast costs for the following twelve months. A stable client population – as in Medicare – is thus required, a challenge in Medicaid given the “churning” of the client base.

Each of these three challenges would seem to apply equally to the ACA state exchanges. Regulators will rely on insurers’ accounting of client health conditions, and as there is no public FFS option they will not have their own cost and claims data. And as the exchanges serve those too rich for Medicaid but not so well off as to have employer insurance, their clients will likely come and go based on outside options – if their situation improves, then they will move into employer insurance; if their situation deteriorates, then they may need to switch to Medicaid.

With Medicaid Managed Care, the ACA exchanges, Medicare Part D and the prominence of Medicare premium-support proposals, the U.S. is moving rapidly toward providing public health insurance through a model of competing, capitated private insurance plans. Past work has identified challenges associated with this model, including the increase in costs that come with insurers losing monopsony bargaining power over providers and consumers’ cognitive overload from choosing among a large set of options. Our work points to an additional concern arising from consumer choice – it tempts insurers to under-serve high-cost clients in the hope they will switch to a competitor.

http://www.nber.org/papers/w19198

Comment:

By Don McCanne, M.D.

The conclusions of this study are shocking, even if predictable.

It has already been established that private Medicare Advantage plans engage in surreptitious activities that result in enrollment of lower-cost, healthier patients, while both avoiding higher-cost patients, and engaging in behaviors that cause higher-cost patients to disenroll (cherry picking and lemon dropping). This shifts higher-cost patients to the traditional public Medicare program, while the private insurers increase profits by continuing to game risk selection.

This study is different because all of the Medicaid patients who were formerly insured through a public program were transferred to private Medicaid managed care programs. Thus there was no public program where the private plans could dump their high-cost patients. So what did they do? They dumped them on their private Medicaid managed care competitors!

What is particularly shocking is the way they did it. They spent more money on the healthier patients to keep them contented so they would stay in their plans, while reducing spending and giving worse service to their higher-cost patients, ensuring dissatisfaction because of the worse outcomes that the patients suffered. Particularly distressing to advocates of social justice is that the high-cost patients discriminated against in this Texas study were predominantly black.

This study provides an important lesson for the insurance exchanges being established under the Affordable Care Act. Since a “public option” was rejected, the exchanges will include only private plans competing with each other. What kind of behavior can we expect? The most effective way for the private insurers to dump high-cost patients onto their competitors will be to give them worse care with terrible outcomes, causing their patients to flee. Of course, there is nowhere else to turn except to other private insurers, though some patients might even consider that paying a penalty for remaining uninsured might be a better option. Then again, remaining uninsured is not a realistic option for those who need higher-cost care.

It’s the same old bottom line. We can either have a publicly administered system dedicated to a patient service ethic, or we can have a privately administered insurance system dedicated to a common business ethic, no matter how cutthroat. Aren’t we making the wrong choice?

Independence Day

By Andrew D. Coates, M.D., F.A.C.P.
WAMC Northeast Public Radio, July 5, 2013

Some day I hope our national holidays will become occasions for a full stop, protected time for all to reflect upon our lives and our world, our individual and shared aspirations. These days holidays seem, at best, more of a rolling pause, the kind of half-hearted braking that brings, at a stop sign, a traffic ticket.

Such is the momentum of contemporary working life in America, where multi-income households are tethered together with evanescent employments and lifelong debts are the price of higher education. When it comes to a time of personal need, when illness strikes, seeking care often introduces unexpected hassles, followed by financial hardship. In serious illness, the unpaid sacrifice of women family members remains the order of the day.

Recently I’ve participated in dialogue with fellow physicians around the nation about the kind of medicine we would like to practice – the vision we share of what good we might do for the nation if we could win a health program that would meet the health needs of everyone.

A health system that belonged to all of us would serve every patient’s needs and remove the hassles, the fear and the money from caregiving. This would prove liberating not only for patients and their families, but for their caregivers.

Yet as the president’s Affordable Care Act is implemented, we see not only the perpetuation of so many unnecessary and irrational arrangements in our health system, but a new push to piece out care as discrete commercial products, not a calling to serve human beings.

From this viewpoint it seems, today, too easy to despair. Writing over a decade ago, the great American physician and author Eric Cassell captured the full weight of this despairing insight: “Perhaps it will turn out that American democracy simply cannot meet its historical and fundamental promise of equity, and it is in medical care that its failure will be decisively demonstrated.”[1]

Our health system, with such enormous potential to ameliorate disparities and erase injustice, presently often functions in a manner that instead exacerbates social inequities. Yet we all know it doesn’t need to be this way.

The solution is a national health program that would meet the needs of everyone, be free to patients at the point of delivery, based upon clinical needs not the ability to pay. Such a system would mitigate our present chasm between rich and poor, lowering the Gini coefficient.

With access to health care freed from dependence upon private insurance through an employer or a spouse or proving Medicaid eligibility, personal liberation would follow. Our patients would be free of so much fear, hassle, and financial hardship.

But how will we get there from here? My colleagues want a road map. What will it take to win a health system we will truly call our own?

It will take an enormous and historic shift, social forces beyond our control. For all of our power and privilege as physicians, we will not dictate the course of history. Nor can we simply avail ourselves of the existing power structure. During the previous century public health systems were won in spite of democratic power structures, not because of them.

Universal health care, nation by nation, has resulted from victorious campaigns by political parties based upon trade unions, by the threat of social revolution or by social revolution itself. Today in the United States, the mass movement for national health care is incipient, not full-blown, and commercial interests have seized the day. As scandal after scandal comes down, more people are tuning out and there seems even more reason for despair.

The Declaration of Independence says that governments derive their just powers from the consent of the governed. One hundred fifty-six years ago here in upstate New York, at a time when the abolition of slavery still seemed impossible, the great abolitionist and former slave Frederick Douglass observed: “Find out just what any people will quietly submit to and you have found out the exact measure of injustice and wrong which will be imposed upon them.”[2]

So today let’s stop and think about what it means to articulate our vision of public health care for all. We not only announce that we will not quietly submit to the further commercialization of caregiving. We expose unnecessary injustice and preventable wrong. By our words and deeds we find our road map toward great historic change.

When our health system truly becomes our own – and we finally muster, rather than squander, our health resources – we will find a new day of independence for modern caregiving and for everyone in the United States.

***

1. Eric Cassell in “The Goals of Medicine: The Forgotten Issues in Health Care Reform,” Mark J. Hanson, Daniel Callahan, eds., Georgetown University Press, 1999, p. 114.

2. Douglass, Frederick. [1857] (1985). “The Significance of Emancipation in the West Indies.” Speech, Canandaigua, New York, August 3, 1857; collected in pamphlet by author. In The Frederick Douglass Papers. Series One: Speeches, Debates, and Interviews. Volume 3: 1855-63. Edited by John W. Blassingame. New Haven: Yale University Press, p. 204.

Dr. Andrew Coates practices internal medicine in upstate New York. He is president of Physicians for a National Health Program.

Increased risk of death among uninsured neonates

Increased Risk of Death among Uninsured Neonates

By Frank H. Morriss Jr
Health Services Research (HSR), August 2013

Abstract

Objective

To estimate the contribution of health insurance status to the risk of death among hospitalized neonates.

Data Sources

Kids’ Inpatient Databases (KID) for 2003, 2006, and 2009.

Study Design

KID 2006 subpopulation of neonatal discharges was analyzed by weighted frequency distribution and multivariable logistic regression analyses for the outcome of death, adjusted for insurance status and other variables. Multivariable linear regression analyses were conducted for the outcomes mean adjusted length of stay and hospital charges. The death analysis was repeated with KID 2003 and 2009.

Principal Findings

Of 4,318,121 estimated discharges in 2006, 5.4 percent were uninsured. There were 17,892 deaths; 9.5 percent were uninsured. The largest risks of death were five clinical conditions with adjusted odds ratios (AOR) of 13.7–3.1. Lack of insurance had an AOR of 2.6 (95 percent CI: 2.4, 2.8), greater than many clinical conditions; AOR estimates in alternate models were 2.1–2.7. Compared with insureds, uninsureds were less likely to have been admitted in transfer, more likely to have died in rural hospitals and to have received fewer resources. Similar death outcome results were observed for 2003 and 2009.

Conclusions

Uninsured neonates had decreased care and increased risk of dying.

From the Discussion:

Effects of Insurance Status

As expected, the predictors with the largest adjusted risks for death during hospitalization of neonatal patients estimated using the KID 2006 database were clinical conditions commonly encountered in neonatal intensive care units, that is, PT/LBW/IUGR, IVH, hypoxia, NEC, and congenital malformation. In this analysis, uninsured status was the next largest adjusted risk for death, for which the AOR, 2.6, was greater than those for sepsis, obstetrical conditions and complications, RDS, multiple birth, and male gender. Lack of insurance was also a significant predictor of death in analyses of both the 2003 and 2009 KID databases. The estimate of the effect of insurance was not changed in models for the outcome of death that excluded the hospital variable, indicating that the disparity is a within-hospital disparity.

Socioeconomic Position, Relative Isolation, and Race

Socioeconomic position, place of residence, race, and health insurance status are interrelated factors, each of which may independently predict the hospital death of a newborn, adjusted for clinical predictors and each other. However, it is difficult to separate the effect of lack of health insurance in the United States from socioeconomic conditions that may predispose to that condition. A significant unadjusted association exists in this analysis between uninsured status and the distribution of median household income indicated by ZIP code toward lower quartiles; a separate association exists between uninsured status and rural residence. Measures of poverty, income inequality, and social deprivation, not including health insurance status, have been associated with adverse neonatal or infant survival risks (Singh and Kogan 2007; Olson et al. 2010).

http://onlinelibrary.wiley.com/doi/10.1111/1475-6773.12042/full

Comment:

By Don McCanne, M.D.

Although socioeconomic factors play an important role in neonatal mortality, it is clear that lack of health insurance is an important contributor to these tragic deaths. We have much to do as a society to correct these injustices, but perhaps the easiest first step would be to ensure that everyone is automatically insured, including neonates. The Affordable Care Act will not do that, whereas enacting a single payer national health program would.

Transferring patients to Medicaid managed care

Transitioning Beneficiaries with Complex Care Needs to Medicaid Managed Care: Insights from California

The Kaiser Commission on Medicaid and the Uninsured, June 2013

Between June 2011 and May 2012, the California Medicaid program (known as Medi-Cal) transitioned just under 240,000 seniors and persons with disabilities (SPDs) from fee-for-service to mandatory Medicaid managed care (MMC) as part of its “Bridge to Reform” Medicaid Waiver. Goals of the transition were to increase plan and provider accountability and oversight, improve beneficiary access to care, and make costs more predictable. This study examined how health service providers, plan administrators, and community-based organizations (CBOs) in Contra Costa, Kern, and Los Angeles counties experienced the transition of SPDs to MMC. Below are some key study findings that may help inform future transitions to managed care for populations with complex health needs.

TRANSITION READINESS: BENEFICIARY DATA AND INFORMATION SHARING

* Incomplete or out-of-date contact information for SPDs was an obstacle to notifying beneficiaries of the transition to MMC.

* Health plans experienced barriers contacting beneficiaries by phone to complete Health Risk Assessments.

* The transfer of health and prescription history information from the state to health plans and providers was not timely.

* The delay in obtaining medical records also made it harder for providers to effectively care for new patients.

* Delegation to other health plans or IPAs sometimes caused further delays in data transfer as well as confusion about which entity was responsible for covering certain types of care.

* The SPD transition disrupted established communication channels between primary and specialty care providers.

PROVIDER NETWORKS: BUILDING ADEQUATE CAPACITY

* Health plans experienced barriers recruiting primary care providers with expertise in complex care management.

* Health plans faced challenges recruiting specialty care providers, particularly given the wide range of conditions among the SPD population.

* The reluctance of FFS providers to join plan networks was a major barrier to network expansion.

CARE COORDINATION: NEW RESPONSIBILITIES AND EXPECTATIONS

* Primary care providers have more responsibility for care coordination for SPDs patients but feel unprepared and untrained for this activity.

* Health plans are providing care coordination to SPD who called the member services line up to 4 times as often as other beneficiaries.

* While care coordination has expanded on all fronts, the transition to managed care added complexities that generated even greater need for coordination.

* The mental health services “carve-out” poses barriers to care coordination.

ORGANIZATIONAL RESOURCES: ENSURING ADEQUATE TRANSITION SUPPORT

* Providers reported that the SPD transition taxed their staff resources.

* Providers reported providing unreimbursed care during the transition to prevent potentially dangerous disruptions in care.

* Some plans reported that Medi-Cal capitation rates for SPDs do not account for the much higher utilization rates of the population.

*  Community-based organizations (CBOs) used resources to assist SPDs with the transition to managed care.

The usage of Medicaid managed care delivery models have been increasing nationally, a trend which is likely to continue due to the coverage expansion under the ACA. Even when steps are taken to mitigate anticipated issues and concerns prior to the transition, as was the case with California, unanticipated challenges are likely to arise. Learning from California’s experience with their SPD transition, this brief presents considerations for states, health plans, CBOs, and providers as they prepare for managed care expansions. Particularly salient are the findings around timing, communication, and coordination, including the establishment of partnerships that enable plans and providers to deliver efficient and effective care that meets beneficiaries’ health care needs.

http://kaiserfamilyfoundation.files.wordpress.com/2013/06/8453-transitioning-beneficiaries-with-complex-care-needs.pdf

Comment:

By Don McCanne, M.D.

Although transferring patients to Medicaid managed care plans is supposed to improve access to care, this report shows that access was impaired as patients lost the choice of their health care providers, and experienced disruption in the continuity of their care. Although some of the problems were transitional, many represent substantial impairment in the quality and delivery of health care services. It’s disgraceful.

We need to return these patients to the health care professionals and institutions of their choice, while providing first dollar coverage for their care. In fact, we need to do that for all of us. Think single payer.

Anthony Weiner's single-payer plan is progressive, but not single-payer

By Reid Pillfant
Capital New York, July 3, 2013

Advocates for a single-payer health care plan see plenty of reasons to like Anthony Weiner’s proposed overhaul of the city’s health system. They just think it’s mislabeled.

“Well as I understand his proposal, it’s not what I would call a single-payer proposal, but it has some useful elements,” said David Himmelstein, a professor of public health at Hunter College, and a co-founder of Physicians for a National Health Program.

Weiner has made health care the key component of his mayoral campaign so far, pledging to implement a single-payer plan like the one he loudly argued for during the national debate over health care back in 2009.

Back then, Weiner seemed motivated primarily by a desire for national publicity, actually delivering a message on health care that served him well politically but was at odds with the president’s agendaand that of more serious Democratic advocates of universal health care in Congress. 

While Weiner clearly sees a political opportunity in health care reform now as well, he is at least advocating something that, as mayor, he’d theoretically have a chance of putting into practice.

“Single-payer health care is on the ballot,” Weiner proclaimed in the subject line of a fund-raising email last month, a few days after Weiner devoted his first big policy speech to his health care plan, at an event his campaign dubbed “Big Thought Thursday.”

A subsequent email to a list of Hillary Clinton’s 2008 alumni asked, “Will you help Anthony stand up for single-payer health care?“

Weiner’s basic idea is to convene a task force of city department heads and nonprofit leaders to design an overhaul of the city’s health care system, in order to consolidate the nearly $16 billion the city spends each year on health care into a single system overseen by a deputy mayor for health care innovation. 

“We should make New York City the single-payer laboratory for the rest of the country,” he said at his policy speech.

By his own admission, the plan is a rough sketch, with details to be filled in by the task force. 

But the crux of the idea is that municipal workers and retirees could be united under a single health insurance plan, overseen by the city, which could also cover undocumented immigrants not covered by President Obama’s new health reforms, with an eye toward one day opening the city’s plan to all New Yorkers.

That’s something advocates of universal health care would certainly regard as progress, even if it’s not anything they’d recognize as single-payer.

“Single-payer really means there’s just one payer left in the health care system,” said Himmelstein. “You can’t really do that as the mayor of New York, because Medicare would still exist and private employers, private plans would still exist, so there would still be multiple payers. But I think having a large public plan that encompasses a large piece of the market makes a lot of sense.”

Asked by WNYC’s Brian Lehrer on July 3 whether the plan could accurately be billed as single-payer, Weiner responded by talking generally about the inefficiencies in the current model, and then said, “I guess the best way to look at this is, this is for city workers, for the uninsured, for retirees, this would be Medicare for all New Yorkers who are eligible. But I’m also going to try to expand this to cover the undocumented who are not going to be covered under Obamacare who are going to cost us a great deal of money if we don’t cover them.”

Health care reformers say the potential benefits of Weiner’s plan are great, with the possibility of expanding coverage to more New Yorkers, while reducing the profit-making role of insurance companies and utilizing the city’s leverage to reduce rates and drive down premiums.

“His thinking on health coverage is certainly in the right place,” said Assemblyman Dick Gottfried, who has repeatedly sponsored bills in Albany to create a statewide single-payer system (and who has not endorsed anyone for mayor). “And part of that thinking is the notion that a publicly run plan with as broad a base as possible can do a much better job than relying on insurance companies as a middle man.”

But the potential implementation could be difficult.

Himmelstein said insurance companies would “fight tooth and nail to stop this from happening,” since any talk of containing costs is essentially “cost-containment from their hide.”

Weiner has been dismissive of that kind of opposition.

In his speech, Weiner said the city could leverage its power within the existing private insurance structure, or that it could wholly control the plan, or a hybrid option, with the city contracting an insurance company for administrative costs, like Medicare and Medicaid do. But he made clear that he wasn’t at all concerned with preserving their profits in the current system.

“It’s not my burden as the mayor of the city of New York to protect that,” he said. “My burden as the mayor of the city of New York is to get reasonable costs for high-quality care.” The first line of his fund-raising email touting single-payer read as follows: “If you are a health insurance executive, you may want to stop reading right here.”

He has also struck a combative posture with regard to municipal unions, who he has suggested should pay 10 percent of their own premiums (25 percent for smokers). Weiner has framed the contributions as way of reducing costs and saving the city money that might then be put toward new union contracts that include raises. But the unions, which are some of the most politically powerful in the city, might prefer the raises without the new system, or the added contributions.

“The experience of doing this in other contexts has been challenging because the employees are not always happy to move into whatever plan the city might set up,” said Dr. Sherry Glied, a professor at Columbia’s Mailman School of Public Health and a former Assistant Secretary for Planning and Evaluation in the Department of Health and Human Services under President Obama.

(Himmelstein and Gottfried both suggested Weiner’s fixed-rate contribution was less desirable than a system that spreads the costs, since Weiner’s proposal would extract roughly the same contribution payment from, say, a highly paid CUNY chancellor as it would an administrative assistant or bus driver, who earns significantly less.)

Asked about the need for state or federal support, Weiner, referring to his proposed task force, said “there is no one who is sitting at that table who really needs to get a go-ahead from the state or federal government.”

But any attempts to extend his proposals beyond municipal workers, toward a more robust public plan that would be open to all New York City residents—something more akin to a single-payer system or a public option—would have to navigate a thicket of state and federal regulations.

Covering the undocumented population also presents its own set of problems, since undocumented immigrants are expressly barred from receiving any of the federal subsidies that generally apply to other low-income populations.

Medicaid and Medicare are largely covered by state and federal requirements, with Maryland as the only state that currently en
joys a federal waiver to negotiate its own rates (a waiver the state is fighting to preserve). 

“I think if there’s going to be a single-payer system, given the way that health care is regulated in our country, it will have to be at a state level at the least, or at the federal level,” said Glied, who suggested the city’s efforts might be better focused on enrolling the uninsured in the national reforms set to take effect next year. “It would just be very difficult to manage it, given the governance structure of health insurance and health care delivery, at a city level.”

http://capitalnewyork.com/article/politics/2013/07/8531448/anthony-weiners-single-payer-plan-progressive-not-single-payer

PNHP note: For additional commentary on Weiner’s proposal, see Leonard Rodberg’s blog posting titled “Should we support Anthony Weiner’s ‘single-payer’ plan?“

Idaho AFL-CIO endorses H.R. 676, national single-payer health care

By Kay Tillow
Single Payer News, July 1, 2013

Rian Van Leuven, president of the Idaho State AFL-CIO, announced that on June 12, 2013, the delegates to the 55th Annual Idaho State AFL-CIO Convention passed a resolution to publicly endorse and support H.R. 676, single-payer health care.

Further the resolution states, “That the Idaho State AFL-CIO will develop working relationships with community organizations in Idaho which advocate for single-payer health care and Medicaid expansion.”

Louis Schlickman, M.D., an Idaho physician who practices in Meridian and is co-chair of the Physicians for a National Health Program state chapter, showed the movie “Escape Fire” and made a single-payer presentation to the convention prior to the passage of the resolution.

After the resolution for H.R. 676 was passed by the Idaho State AFL-CIO Convention, Dr. Schlickman stated, “Collectively we are all realizing that unions in general can play a huge role in helping others, not just union workers, see the merit in a single-payer financing system of care.”

Dr. Schlickman observed that union members “have seen how one unexpected illness or injury leads to significant catastrophes of health and income status. And most important, they understand the issue of solidarity.”

Idaho is the 43rd state AFL-CIO federation to endorse H.R. 676, which was introduced into the 113th Congress by Representative John Conyers, D-Mich. The bill is subtitled “Expanded and Improved Medicare for All.”

*****

H.R. 676 would institute a single payer health care system by expanding a greatly improved Medicare to everyone residing in the U. S.

H.R. 676 would cover every person for all necessary medical care including prescription drugs, hospital, surgical, outpatient services, primary and preventive care, emergency services, dental (including oral surgery, periodontics, endodontics), mental health, home health, physical therapy, rehabilitation (including for substance abuse), vision care and correction, hearing services including hearing aids, chiropractic, durable medical equipment, palliative care, podiatric care, and long-term care.

H.R. 676 ends deductibles and co-payments. H.R. 676 would save hundreds of billions annually by eliminating the high overhead and profits of the private health insurance industry and HMOs.

In the current Congress, H.R. 676 has 43 co-sponsors in addition to Rep. Conyers.

H.R. 676 has been endorsed by 604 union organizations including 145 Central Labor Councils/Area Labor Federations and 43 state AFL-CIOs (KY, PA, CT, OH, DE, ND, WA, SC, WY, VT, FL, WI, WV, SD, NC, MO, MN, ME, AR, MD-DC, TX, IA, AZ, TN, OR, GA, OK, KS, CO, IN, AL, CA, AK, MI, MT, NE, NJ, NY, NV, MA, RI, NH, & ID).

For further information, a list of union endorsers, or a sample endorsement resolution, contact:

Kay Tillow, All Unions Committee for Single Payer Health Care—H.R. 676, c/o Nurses Professional Organization (NPO), 1169 Eastern Parkway, Suite 2218, Louisville, KY 40217. Phone: (502) 636-1551, E-mail: nursenpo@aol.com. www.unionsforsinglepayer.org