PNHP

It’s not profit that is destroying our health; it’s the private insurance business model

It’s not profit that is destroying our health; it’s the private insurance business model

By Samuel Metz, M.D.
Firedoglake, Dec. 3, 2012

Many Europeans use private health insurance companies, a few of them for-profit. These Europeans enjoy better care for more people at lower cost than we do. But the European business model differs radically from that in the U.S. In fact, American insurance companies find the European model not only alien, but intolerable. Imagine American insurance companies playing by these European rules:

* You can set any price on your policy, but you must sell it at the same price to everyone, regardless of health.

* You must sell a policy to anyone who applies, no exceptions.

* No policy can be cancelled for any reason, not even failure to pay (the government will step in). Patients, however, can change companies without notice.

* Every policy must cover all treatable diseases. No matter what policy they purchase, patients will never risk destitution (or death) if they suffer a treatable condition.

* Your company must pay every claim from every licensed provider within 30 days. You can protest the payment, but only after you pay the bill.

* Every provider receives the same payment for the same service, regardless of patient or their insurance.

* Your records are an open book. Every dollar (or Euro) that passes through your hands is open to the public. There are no proprietary secrets.

* If you still manage to cherry pick healthier patients, the government will impose a premium to subsidize other companies with sicker patients.

With this model, European companies compete with lower prices, extra benefits, and better customer service. Isn’t that a refreshing change?

The American business model has no such rules. How do American insurance companies compete?

* They avoid sick patients. Highly paid underwriters detect potentially expensive patients before policies are offered. And the best way to avoid sick patients is with high policy prices.

* They slash benefits. Reduced benefits both discourage sick patients from buying a policy and reduce provider payments if they do.

* They pass costs to patients with increased deductibles and co-pays. Healthy patients (the ones companies want to keep) won’t notice because they don’t need health care. At least until they get sick.

* They delay or deny provider payments. If the payment process is frustrating enough, many providers simply give up trying to collect. That’s money they keep.

Profit? No difference. To succeed, both for-profit and not-for-profit companies follow the same rules. If not, your company is toast.

It is not profits but the business model that places the financial interests of our health insurance industry in opposition to the medical interests of its clients. Neither removing profits, nor enhancing competition, nor deregulation will increase health care quality or make health care more accessible.

Our American insurance business model is the source, not the solution, of our health care problems. We must run – not walk – away from letting private insurance companies determine our health care.

Samuel Metz is a Portland anesthesiologist active in health care reform. He is also a member of two organizations advocating publicly funded universal health care: Mad As Hell Doctors and Physicians for a National Health Program. He is the local chapter representative of Health Care for All Oregon, an umbrella organization of over 50 groups working for better health care in Oregon.

http://my.firedoglake.com/healthcareforall/2012/12/03/its-not-profit-that-is-destroying-our-health-its-the-private-insurance-business-model/

Obamacare architect leaves White House for pharmaceutical industry job

Few people embody the corporatist revolving door greasing Washington as purely as Elizabeth Fowler

By Glenn Greenwald
The Guardian (U.K.), Dec. 5, 2012
      
When the legislation that became known as “Obamacare” was first drafted, the key legislator was the Democratic Chairman of the Senate Finance Committee, Max Baucus, whose committee took the lead in drafting the legislation. As Baucus himself repeatedly boasted, the architect of that legislation was Elizabeth Fowler, his chief health policy counsel; indeed, as Marcy Wheeler discovered, it was Fowler who actually drafted it. As Politico put it at the time: “If you drew an organizational chart of major players in the Senate health care negotiations, Fowler would be the chief operating officer.”

What was most amazing about all of that was that, before joining Baucus’ office as the point person for the health care bill, Fowler was the Vice President for Public Policy and External Affairs (i.e. informal lobbying) at WellPoint, the nation’s largest health insurance provider (before going to WellPoint, as well as after, Fowler had worked as Baucus’ top health care aide). And when that health care bill was drafted, the person whom Fowler replaced as chief health counsel in Baucus’ office, Michelle Easton, was lobbying for WellPoint as a principal at Tarplin, Downs, and Young.

Whatever one’s views on Obamacare were and are: the bill’s mandate that everyone purchase the products of the private health insurance industry, unaccompanied by any public alternative, was a huge gift to that industry; as Wheeler wrote at the time: “to the extent that Liz Fowler is the author of this document, we might as well consider WellPoint its author as well.” Watch the five-minute Bill Moyers report from 2009, embedded here, on the key role played in all of this by Liz Fowler and the “revolving door” between the health insurance/lobbying industry and government officials at the time this bill was written and passed.

More amazingly still, when the Obama White House needed someone to oversee implementation of Obamacare after the bill passed, it chose . . . Liz Fowler. That the White House would put a former health insurance industry executive in charge of implementation of its new massive health care law was roundly condemned by good government groups as at least a violation of the “spirit” of governing ethics rules and even “gross,” but those objections were, of course, brushed aside by the White House. She then became Special Assistant to the President for Healthcare and Economic Policy at the National Economic Council.

Now, as Politico’s “Influence” column briefly noted on Tuesday, Fowler is once again passing through the deeply corrupting revolving door as she leaves the Obama administration to return to the loving and lucrative arms of the private health care industry: “Elizabeth Fowler is leaving the White House for a senior-level position leading ‘global health policy’ at Johnson & Johnson’s government affairs and policy group.”

The pharmaceutical giant that just hired Fowler actively supported the passage of Obamacare through its membership in the Pharmaceutical Researchers and Manufacturers of America (PhRMA) lobby. Indeed, PhRMA was one of the most aggressive supporters — and most lavish beneficiaries — of the health care bill drafted by Fowler. Mother Jones’ James Ridgeway proclaimed “Big Pharma” the “big winner” in the health care bill. And now, Fowler will receive ample rewards from that same industry as she peddles her influence in government and exploits her experience with its inner workings to work on that industry’s behalf, all of which has been made perfectly legal by the same insular, Versailles-like Washington culture that so lavishly benefits from all of this.

It’s difficult to find someone who embodies the sleazy, anti-democratic, corporatist revolving door that greases Washington as shamelessly and purely as Liz Fowler. One of the few competitors I can think of is Adm. Michael McConnell, who parlayed his military and intelligence career into a lucrative gig at Booz Allen, one of the nation’s largest private intelligence contractors; then became George W. Bush’s Director of National Intelligence (where he spearheaded a huge gift to the telecom industry — retroactive immunity shielding it from all accountability for its participation in the illegal Bush NSA eavesdropping program — as well as continued his Booz Allen work of privatizing intelligence and surveillance functions); then returned to the loving arms of Booz Allen, where he now exploits his national security credentials on behalf of industry interests (by, for instance, spearheading the fear-mongering campaign about cyber-warfare in order to advocate for security programs that would amply enrich Booz Allen’s clients).

This is precisely the behavior which, quite rationally, makes the citizenry so jaded about Washington. It’s what ensures that the interests of the same permanent power factions are served regardless of election outcomes. It’s what makes a complete mockery out claims of democracy. And it’s what demonstrates that corporatism and oligarchy are the dominant forms of government in the US.

http://www.guardian.co.uk/commentisfree/2012/dec/05/obamacare-fowler-lobbyist-industry1

Physicians find insurer ACO payment models "completely unfavorable"

Medical practices wary of insurer efforts on new payment programs

By Victoria Stagg Elliott
American Medical News, December 3, 2012

Medical practices have a low opinion of how insurers are operating emerging payment programs, such as accountable care organizations, patient-centered medical homes, shared savings and payment bundling, according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.

Researchers asked practices to rate the willingness of seven large payers to engage in innovative models on a scale of one, meaning completely unwilling, to five, which indicates completely willing. Medicare Part B scored the highest at 1.95, and United Healthcare was the highest private payer at 1.82.

When asked to rate the favorability of these payment models to the practice on a scale of one to five, Medicare Part B scored highest at 1.68.

Health industry insiders said the scores on innovative payment models reflect physicians’ frustrations with programs they believe were not designed for their specialty or size, and that insurers were not flexible in negotiating terms.

ACOs serve 25 million to 31 million patients, a “remarkable achievement for a care arrangement that was scarcely on the map at all two years ago,” according to a report released Nov. 26 by management consulting company Oliver Wyman.

Cigna’s collaborative accountable care program includes 42 participating entities, mostly large, with about 10,000 physicians providing care for 400,000 members. A paper in the November Health Affairs found the plan’s ACO program improved quality and lowered costs.

http://www.ama-assn.org/amednews/2012/12/03/bisa1203.htm?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20121203

And…

Practice Perspectives on Payer Performance, 2012

MGMA-ACMPE

For the fifth year in a row, the Medical Group Management Association (MGMA) has conducted its poll to determine group practice professionals’ attitudes about payer interactions.

Of the payers who are willing to engage in innovative payment models (accountable care, shared savings, medical homes or payment bundling), how favorable or unfavorable do you consider these options to be to your practice?

Rating average / Payer

1.68  Medicare Part B
1.62  United Healthcare
1.62  Aetna
1.58  Cigna
1.57  Anthem
1.55  Humana
1.48  Coventry

(Based upon a 5 point scale where 1 = Completely unfavorable, 2 = Moderately unfavorable, 3 = Neutral, 4 = Moderately favorable, and 5 = Completely favorable.)

http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=1372690

And…

A Collaborative Accountable Care Model In Three Practices Showed Promising Early Results On Costs And Quality Of Care

By Richard B. Salmon, Mark I. Sanderson, Barbara A. Walters, Karen Kennedy, Robert C. Flores and Alan M. Muney
Health Affairs, November 2012

Cigna’s Collaborative Accountable Care initiative provides financial incentives to physician groups and integrated delivery systems to improve the quality and efficiency of care for patients in commercial open-access benefit plans.

Although not statistically significant, these early results revealed favorable trends in total medical costs and quality of care.

http://content.healthaffairs.org/content/31/11/2379.abstract

Comment:

By Don McCanne, MD

These early results should sound the alarms on our current efforts to implement accountable care organizations (ACOs). We’ve barely begun and already about 30 million patients have been assigned to ACOs. Yet look at how that is working.

Health care professionals in group practices were polled on how favorable or unfavorable the insurers’ innovative payment models, primarily ACOs, were to their practices. The average rating for all insurers was in the 1s – “completely unfavorable”!

Further, we are now seeing the same response from the insurers that we did with earlier efforts at managed care. They were telling us then that we were receiving higher quality care at lower cost. As it turned out, costs continued to rise and quality remained mediocre.

Now Cigna is reporting that the recent Health Affairs article that they authored showed that their “ACO program improved quality and lowered costs.” Yet the article actually states that these early results were “not statistically significant.”

This turkey has already taken off, and yet it can’t fly. The health care of 30 million patients is already at stake, and they are being cared for health care professionals who find the arrangement COMPLETELY UNFAVORABLE!

Physicians find insurer ACO payment models “completely unfavorable”

Medical practices wary of insurer efforts on new payment programs

By Victoria Stagg Elliott
American Medical News, December 3, 2012

Medical practices have a low opinion of how insurers are operating emerging payment programs, such as accountable care organizations, patient-centered medical homes, shared savings and payment bundling, according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.

Researchers asked practices to rate the willingness of seven large payers to engage in innovative models on a scale of one, meaning completely unwilling, to five, which indicates completely willing. Medicare Part B scored the highest at 1.95, and United Healthcare was the highest private payer at 1.82.

When asked to rate the favorability of these payment models to the practice on a scale of one to five, Medicare Part B scored highest at 1.68.

Health industry insiders said the scores on innovative payment models reflect physicians’ frustrations with programs they believe were not designed for their specialty or size, and that insurers were not flexible in negotiating terms.

ACOs serve 25 million to 31 million patients, a “remarkable achievement for a care arrangement that was scarcely on the map at all two years ago,” according to a report released Nov. 26 by management consulting company Oliver Wyman.

Cigna’s collaborative accountable care program includes 42 participating entities, mostly large, with about 10,000 physicians providing care for 400,000 members. A paper in the November Health Affairs found the plan’s ACO program improved quality and lowered costs.

http://www.ama-assn.org/amednews/2012/12/03/bisa1203.htm?utm_source=nwltr&utm_medium=heds-htm&utm_campaign=20121203

And…

Practice Perspectives on Payer Performance, 2012

MGMA-ACMPE

For the fifth year in a row, the Medical Group Management Association (MGMA) has conducted its poll to determine group practice professionals’ attitudes about payer interactions.

Of the payers who are willing to engage in innovative payment models (accountable care, shared savings, medical homes or payment bundling), how favorable or unfavorable do you consider these options to be to your practice?

Rating average / Payer

1.68  Medicare Part B
1.62  United Healthcare
1.62  Aetna
1.58  Cigna
1.57  Anthem
1.55  Humana
1.48  Coventry

(Based upon a 5 point scale where 1 = Completely unfavorable, 2 = Moderately unfavorable, 3 = Neutral, 4 = Moderately favorable, and 5 = Completely favorable.)

http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=1372690

And…

A Collaborative Accountable Care Model In Three Practices Showed Promising Early Results On Costs And Quality Of Care

By Richard B. Salmon, Mark I. Sanderson, Barbara A. Walters, Karen Kennedy, Robert C. Flores and Alan M. Muney
Health Affairs, November 2012

Cigna’s Collaborative Accountable Care initiative provides financial incentives to physician groups and integrated delivery systems to improve the quality and efficiency of care for patients in commercial open-access benefit plans.

Although not statistically significant, these early results revealed favorable trends in total medical costs and quality of care.

http://content.healthaffairs.org/content/31/11/2379.abstract

Comment:

By Don McCanne, MD

These early results should sound the alarms on our current efforts to implement accountable care organizations (ACOs). We’ve barely begun and already about 30 million patients have been assigned to ACOs. Yet look at how that is working.

Health care professionals in group practices were polled on how favorable or unfavorable the insurers’ innovative payment models, primarily ACOs, were to their practices. The average rating for all insurers was in the 1s – “completely unfavorable”!

Further, we are now seeing the same response from the insurers that we did with earlier efforts at managed care. They were telling us then that we were receiving higher quality care at lower cost. As it turned out, costs continued to rise and quality remained mediocre.

Now Cigna is reporting that the recent Health Affairs article that they authored showed that their “ACO program improved quality and lowered costs.” Yet the article actually states that these early results were “not statistically significant.”

This turkey has already taken off, and yet it can’t fly. The health care of 30 million patients is already at stake, and they are being cared for health care professionals who find the arrangement COMPLETELY UNFAVORABLE!

Physicians find insurer ACO payment models "completely unfavorable"

Medical practices wary of insurer efforts on new payment programs

By Victoria Stagg Elliott
American Medical News, December 3, 2012
Medical practices have a low opinion of how insurers are operating emerging payment programs, such as accountable care organizations, patient-centered medical homes, shared savings and payment bundling, according to a survey of 800 practices released Nov. 14 by MGMA-ACMPE.
Researchers asked practices to rate the willingness of seven large payers to engage in innovative models on a scale of one, meaning completely unwilling, to five, which indicates completely willing. Medicare Part B scored the highest at 1.95, and United Healthcare was the highest private payer at 1.82.
When asked to rate the favorability of these payment models to the practice on a scale of one to five, Medicare Part B scored highest at 1.68.
Health industry insiders said the scores on innovative payment models reflect physicians’ frustrations with programs they believe were not designed for their specialty or size, and that insurers were not flexible in negotiating terms.
ACOs serve 25 million to 31 million patients, a “remarkable achievement for a care arrangement that was scarcely on the map at all two years ago,” according to a report released Nov. 26 by management consulting company Oliver Wyman.
Cigna’s collaborative accountable care program includes 42 participating entities, mostly large, with about 10,000 physicians providing care for 400,000 members. A paper in the November Health Affairs found the plan’s ACO program improved quality and lowered costs.
http://www.ama-assn.org/amednews/2012/12/03/bisa1203.htm?utm_source=nwlt…
And…

Practice Perspectives on Payer Performance, 2012

MGMA-ACMPE
For the fifth year in a row, the Medical Group Management Association (MGMA) has conducted its poll to determine group practice professionals’ attitudes about payer interactions.
Of the payers who are willing to engage in innovative payment models (accountable care, shared savings, medical homes or payment bundling), how favorable or unfavorable do you consider these options to be to your practice?
Rating average / Payer
1.68  Medicare Part B
1.62  United Healthcare
1.62  Aetna
1.58  Cigna
1.57  Anthem
1.55  Humana
1.48  Coventry
(Based upon a 5 point scale where 1 = Completely unfavorable, 2 = Moderately unfavorable, 3 = Neutral, 4 = Moderately favorable, and 5 = Completely favorable.)
http://www.mgma.com/WorkArea/DownloadAsset.aspx?id=1372690
And…

A Collaborative Accountable Care Model In Three Practices Showed Promising Early Results On Costs And Quality Of Care

By Richard B. Salmon, Mark I. Sanderson, Barbara A. Walters, Karen Kennedy, Robert C. Flores and Alan M. Muney
Health Affairs, November 2012
Cigna’s Collaborative Accountable Care initiative provides financial incentives to physician groups and integrated delivery systems to improve the quality and efficiency of care for patients in commercial open-access benefit plans.
Although not statistically significant, these early results revealed favorable trends in total medical costs and quality of care.
http://content.healthaffairs.org/content/31/11/2379.abstract

These early results should sound the alarms on our current efforts to implement accountable care organizations (ACOs). We’ve barely begun and already about 30 million patients have been assigned to ACOs. Yet look at how that is working.
Health care professionals in group practices were polled on how favorable or unfavorable the insurers’ innovative payment models, primarily ACOs, were to their practices. The average rating for all insurers was in the 1s – “completely unfavorable”!
Further, we are now seeing the same response from the insurers that we did with earlier efforts at managed care. They were telling us then that we were receiving higher quality care at lower cost. As it turned out, costs continued to rise and quality remained mediocre.
Now Cigna is reporting that the recent Health Affairs article that they authored showed that their “ACO program improved quality and lowered costs.” Yet the article actually states that these early results were “not statistically significant.”
This turkey has already taken off, and yet it can’t fly. The health care of 30 million patients is already at stake, and they are being cared for health care professionals who find the arrangement COMPLETELY UNFAVORABLE!

Cash upfront for ED visits?

New ED drama? Hospitals demand upfront fee for nonemergencies

By Kevin B. O’Reilly
American Medical News, December 3, 2012

(A small) but growing number of hospitals give patients whose problems are deemed nonemergent a choice: Pay an initial fee to get the problem treated in the ED, or seek care elsewhere. The fees range from $100 to $180 for uninsured patients, or the relevant co-pay or deductible for insured patients.

Hospitals implementing the pay-first policy say it complies with the Emergency Medical Treatment and Active Labor Act because all patients receive the federally required medical screening regardless of ability to pay. It is only after a patient’s condition is deemed nonemergent that upfront payment for further treatment in the ED is discussed.

Yet many doctors interviewed for this article found the growing trend alarming. They said it unfairly targets patients with poor access to primary care and is unlikely to alleviate ED crowding because nonurgent problems make up less than 10% of visits. Emergency physicians added that the policy could result in tragedy, because some seemingly nonemergent conditions quickly worsen, and because some patients with life-threatening problems may wrongly decide to steer clear of the ED to avoid pay-first fees.

The pay trend is severely misguided, said Arthur L. Kellermann, MD, MPH, who served on an Institute of Medicine emergency care panel and now is a health policy researcher at the RAND Corp., an independent nonprofit think tank.

“People don’t go the ER as a recreational event,” he said. “If you tell me you have an urgent care clinic or walk-in clinic or other places where these people can go straight to, then OK. But to tell someone to just go away if you don’t have $150, you have to be ignoring the fact that if they had somewhere to go they wouldn’t be there in the first place. And you have to be damn sure that this patient doesn’t have a more serious problem. This is putting a Band-Aid on a gunshot wound.”

“There are truly people who come to the ED with something very benign, and it ends up being a major medical issue,” said Patrick O’Malley, MD, an emergency physician in a suburb of Columbia, S.C. “Determining who those patients are right at the front door is difficult.”

The pay-first policy appears to be aimed at discouraging uninsured patients from visiting the ED, said Leora Horwitz, MD, assistant professor of general internal medicine at Yale University School of Medicine in Connecticut.

“A much better solution to this kind of problem would be to incentivize primary care doctors to provide the care that’s needed, to have evening hours, weekend hours, and to have more urgent care centers,” Dr. Horwitz said. “There are many ways to improve access for patients without barring the door of the ER as your solution.”

http://www.ama-assn.org/amednews/2012/12/03/prl21203.htm

Comment:

By Don McCanne, MD

Over half of emergency department (ED) visits are truly urgent or emergent and should be seen within minutes. About 35 percent are semi-urgent and should be seen within a couple of hours. Only 8 percent are non-urgent and could be seen the next day. Which of these patients should never be seen in the ED?

If you assume that patients are fully capable of assessing the urgency of their own problems and and that triage nurses are fully capable of never making a judgement error, then perhaps the 8 percent who are non-urgent should be seen by their primary care professionals at the next available appointment. But such an assumption is a stretch since the true urgency often cannot be determined with absolute certainty until there is a full assessment of the problem.

Maybe that head cold is an acute bacterial sinusitis, which could lead to meningitis or an abscess with sepsis. Maybe that gastrocnemius strain is thromboplebitis, which could result in a pulmonary embolism. Maybe that migraine is a rupturing berry aneurysm, which… well, you know. Then again, maybe these really are minor, non-urgent problems that do not need assessment in the ED.

How do you decide that? Do you have the triage nurse make a decision to turn the patient away at the front desk with no further ED evaluation? That can be a problem if the nurse’s initial screen misses a serious problem, which is certainly possible, even if infrequent.

The answer is easy. In this age of consumer-directed health care, you do not turn anyone away. Instead, you require the patient who seems to have a non-urgent problem to use their health care shopping skills by requiring a payment up front. Thus the ultimate decision is not left with the triage nurse but rather is left with the least qualified individual in the ED – the patient.

Some patients will make the wrong decision – bad policy. This is overkill, perhaps literally.

If a local ED is truly overburdened with routine medical problems, the proper management should be to adjust capacity in the health care system. If primary care services need to be extended to evening and weekend hours, improve capacity so that can be done. If the void can be filled with a free-standing urgent care clinic, then establish that. The ED itself could be expanded to include a wing for less urgent problems, staffed with a nurse practitioner of primary care physician, if appropriate for the community. The marginal cost should not be much different from a free-standing, off-hours clinic, if that.

Under a single payer system, some adjustments in capacity can be made by administrators of the global budgets for the facilities. More extensive changes might involve separate budgets established for capital improvements. But creating financial barriers to care runs the risk of having the patient decide to forgo beneficial health care that just might possibly be lifesaving.

If the ED is crowded with the worried well, fix the system. Don’t kill the seriously ill patient hidden amongst them.

Cash upfront for ED visits?

New ED drama? Hospitals demand upfront fee for nonemergencies

By Kevin B. O’Reilly
American Medical News, December 3, 2012
(A small) but growing number of hospitals give patients whose problems are deemed nonemergent a choice: Pay an initial fee to get the problem treated in the ED, or seek care elsewhere. The fees range from $100 to $180 for uninsured patients, or the relevant co-pay or deductible for insured patients.
Hospitals implementing the pay-first policy say it complies with the Emergency Medical Treatment and Active Labor Act because all patients receive the federally required medical screening regardless of ability to pay. It is only after a patient’s condition is deemed nonemergent that upfront payment for further treatment in the ED is discussed.
Yet many doctors interviewed for this article found the growing trend alarming. They said it unfairly targets patients with poor access to primary care and is unlikely to alleviate ED crowding because nonurgent problems make up less than 10% of visits. Emergency physicians added that the policy could result in tragedy, because some seemingly nonemergent conditions quickly worsen, and because some patients with life-threatening problems may wrongly decide to steer clear of the ED to avoid pay-first fees.
The pay trend is severely misguided, said Arthur L. Kellermann, MD, MPH, who served on an Institute of Medicine emergency care panel and now is a health policy researcher at the RAND Corp., an independent nonprofit think tank.
“People don’t go the ER as a recreational event,” he said. “If you tell me you have an urgent care clinic or walk-in clinic or other places where these people can go straight to, then OK. But to tell someone to just go away if you don’t have $150, you have to be ignoring the fact that if they had somewhere to go they wouldn’t be there in the first place. And you have to be damn sure that this patient doesn’t have a more serious problem. This is putting a Band-Aid on a gunshot wound.”
“There are truly people who come to the ED with something very benign, and it ends up being a major medical issue,” said Patrick O’Malley, MD, an emergency physician in a suburb of Columbia, S.C. “Determining who those patients are right at the front door is difficult.”
The pay-first policy appears to be aimed at discouraging uninsured patients from visiting the ED, said Leora Horwitz, MD, assistant professor of general internal medicine at Yale University School of Medicine in Connecticut.
“A much better solution to this kind of problem would be to incentivize primary care doctors to provide the care that’s needed, to have evening hours, weekend hours, and to have more urgent care centers,” Dr. Horwitz said. “There are many ways to improve access for patients without barring the door of the ER as your solution.”
http://www.ama-assn.org/amednews/2012/12/03/prl21203.htm

Over half of emergency department (ED) visits are truly urgent or emergent and should be seen within minutes. About 35 percent are semi-urgent and should be seen within a couple of hours. Only 8 percent are non-urgent and could be seen the next day. Which of these patients should never be seen in the ED?
If you assume that patients are fully capable of assessing the urgency of their own problems and and that triage nurses are fully capable of never making a judgement error, then perhaps the 8 percent who are non-urgent should be seen by their primary care professionals at the next available appointment. But such an assumption is a stretch since the true urgency often cannot be determined with absolute certainty until there is a full assessment of the problem.
Maybe that head cold is an acute bacterial sinusitis, which could lead to meningitis or an abscess with sepsis. Maybe that gastrocnemius strain is thromboplebitis, which could result in a pulmonary embolism. Maybe that migraine is a rupturing berry aneurysm, which… well, you know. Then again, maybe these really are minor, non-urgent problems that do not need assessment in the ED.
How do you decide that? Do you have the triage nurse make a decision to turn the patient away at the front desk with no further ED evaluation? That can be a problem if the nurse’s initial screen misses a serious problem, which is certainly possible, even if infrequent.
The answer is easy. In this age of consumer-directed health care, you do not turn anyone away. Instead, you require the patient who seems to have a non-urgent problem to use their health care shopping skills by requiring a payment up front. Thus the ultimate decision is not left with the triage nurse but rather is left with the least qualified individual in the ED – the patient.
Some patients will make the wrong decision – bad policy. This is overkill, perhaps literally.
If a local ED is truly overburdened with routine medical problems, the proper management should be to adjust capacity in the health care system. If primary care services need to be extended to evening and weekend hours, improve capacity so that can be done. If the void can be filled with a free-standing urgent care clinic, then establish that. The ED itself could be expanded to include a wing for less urgent problems, staffed with a nurse practitioner of primary care physician, if appropriate for the community. The marginal cost should not be much different from a free-standing, off-hours clinic, if that.
Under a single payer system, some adjustments in capacity can be made by administrators of the global budgets for the facilities. More extensive changes might involve separate budgets established for capital improvements. But creating financial barriers to care runs the risk of having the patient decide to forgo beneficial health care that just might possibly be lifesaving.
If the ED is crowded with the worried well, fix the system. Don’t kill the seriously ill patient hidden amongst them.

You are not a loan: 'Rolling Jubilee' takes aim at medical bankruptcy

By George Lavender
New Internationalist blog (U.K.), Nov. 30, 2012

‘Debt is the tie that binds the 99 per cent together,’ says Matthew McLoughlin. ‘Like most Americans I’m struggling …I’ve got $60,000 of student loan debt.’ McLoughlin was an organizer with Occupy in Chicago when he first heard about the Strike Debt campaign. ‘Right away it hit home as a way to further the conversation that the Occupy movement started last year.’

‘A bailout for the 99 per cent’ is how Strike Debt describes the ‘Rolling Jubilee’, plan to abolish millions of dollars in personal debt. The idea is to buy up bundles of distressed debt on the secondary debt market, where it’s sold for a knockdown price of about five per cent of its value and, instead of asking the people concerned to repay it, the debt would be abolished.

It’s an idea that seems to be catching on. Since the campaign’s launch in mid-November 2012, Strike Debt says it has raised enough money from supporters to buy, and then abolish, more than $8.5 million worth of debt. While that represents a tiny fraction of US citizens’ personal debt, the group has much bigger ambitions. ‘The idea behind the Jubilee is providing aid, but it’s also raising awareness.’ explains McLoughlin. He hopes the Rolling Jubilee will highlight the size of the US debt problem and its sources. ‘We don’t feel that we owe these companies anything for the debts they’re trying to collect from us, which are mostly for things that should be guaranteed: like housing, medicine, and higher education.’

Rolling Jubilee will start by buying up medical debt, a problem that afflicts many Americans. As Steffie Woolhandler, a Professor of Public Health at the City University of New York, and a member of Physicians for a National Health Program explains, ‘More than half of all personal bankruptcies in the United States are due, at least in part, to medical illness or medical debt’.

‘Bankruptcy is something I constantly think about.’ says Rebecca Randel, a 39 year-old graduate student, ‘It weighs on me all the time.’ Back in the winter of 2009 Randel had what she calls ‘a classic American healthcare experience’. A week in hospital for emergency treatment left her with $24, 000 of medical costs. Without health insurance and the bills piling up she was forced to use her credit card to make the minimum payments required to keep it from going to collection agencies.  ‘I would have nightmares about how to pay my bills,’ says Randel. ‘I couldn’t sleep at night because I knew I had to make another credit card payment or I was about to max out a credit card.’

Like many people, Randel says she was ashamed of her debt, until she found that she was far from alone. ‘People feel very guilty about unpaid debt,’ says Steffie Woolhandler. ‘They need to remember it’s not their fault they got sick.’ By starting a public conversation about debt, Strike Debt activists say they hope to bring people together to challenge the system that creates it. ‘It’s going to spread like wildfire,’ says Strike Debt organizer, Danielle Villarreal ‘in the same way that ideas about economic inequality did under Occupy, because that was also something that everyone felt and no one was talking about.’ Next, the group plans to organize people who can’t or won’t pay back money they owe, in a co-ordinated debt strike.

So far, Strike Debt has earned praise from some unlikely sources. Business Insider described the Rolling Jubilee as ‘brilliant’, while Forbes ran a column entitled ‘Finally, an Occupy Wall Street Idea We Can All Get Behind’. Meanwhile, Strike Debt groups have sprung up across the US, and further afield, including Britain.

For Nick Mirzoeff, a Professor of Media, Culture and Communication at New York University, tackling debt is just the beginning. ‘This is a way to begin a much wider conversation about what we value in our society,’ he says.‘What we value in people and what we expect a life should be about. We think a life should be about more than just repaying loans, we think people are more than just a loan.’

http://www.newint.org/blog/2012/11/30/strike-debt-personal-debt/

You are not a loan: ‘Rolling Jubilee’ takes aim at medical bankruptcy

By George Lavender
New Internationalist blog (U.K.), Nov. 30, 2012

‘Debt is the tie that binds the 99 per cent together,’ says Matthew McLoughlin. ‘Like most Americans I’m struggling …I’ve got $60,000 of student loan debt.’ McLoughlin was an organizer with Occupy in Chicago when he first heard about the Strike Debt campaign. ‘Right away it hit home as a way to further the conversation that the Occupy movement started last year.’

‘A bailout for the 99 per cent’ is how Strike Debt describes the ‘Rolling Jubilee’, plan to abolish millions of dollars in personal debt. The idea is to buy up bundles of distressed debt on the secondary debt market, where it’s sold for a knockdown price of about five per cent of its value and, instead of asking the people concerned to repay it, the debt would be abolished.

It’s an idea that seems to be catching on. Since the campaign’s launch in mid-November 2012, Strike Debt says it has raised enough money from supporters to buy, and then abolish, more than $8.5 million worth of debt. While that represents a tiny fraction of US citizens’ personal debt, the group has much bigger ambitions. ‘The idea behind the Jubilee is providing aid, but it’s also raising awareness.’ explains McLoughlin. He hopes the Rolling Jubilee will highlight the size of the US debt problem and its sources. ‘We don’t feel that we owe these companies anything for the debts they’re trying to collect from us, which are mostly for things that should be guaranteed: like housing, medicine, and higher education.’

Rolling Jubilee will start by buying up medical debt, a problem that afflicts many Americans. As Steffie Woolhandler, a Professor of Public Health at the City University of New York, and a member of Physicians for a National Health Program explains, ‘More than half of all personal bankruptcies in the United States are due, at least in part, to medical illness or medical debt’.

‘Bankruptcy is something I constantly think about.’ says Rebecca Randel, a 39 year-old graduate student, ‘It weighs on me all the time.’ Back in the winter of 2009 Randel had what she calls ‘a classic American healthcare experience’. A week in hospital for emergency treatment left her with $24, 000 of medical costs. Without health insurance and the bills piling up she was forced to use her credit card to make the minimum payments required to keep it from going to collection agencies.  ‘I would have nightmares about how to pay my bills,’ says Randel. ‘I couldn’t sleep at night because I knew I had to make another credit card payment or I was about to max out a credit card.’

Like many people, Randel says she was ashamed of her debt, until she found that she was far from alone. ‘People feel very guilty about unpaid debt,’ says Steffie Woolhandler. ‘They need to remember it’s not their fault they got sick.’ By starting a public conversation about debt, Strike Debt activists say they hope to bring people together to challenge the system that creates it. ‘It’s going to spread like wildfire,’ says Strike Debt organizer, Danielle Villarreal ‘in the same way that ideas about economic inequality did under Occupy, because that was also something that everyone felt and no one was talking about.’ Next, the group plans to organize people who can’t or won’t pay back money they owe, in a co-ordinated debt strike.

So far, Strike Debt has earned praise from some unlikely sources. Business Insider described the Rolling Jubilee as ‘brilliant’, while Forbes ran a column entitled ‘Finally, an Occupy Wall Street Idea We Can All Get Behind’. Meanwhile, Strike Debt groups have sprung up across the US, and further afield, including Britain.

For Nick Mirzoeff, a Professor of Media, Culture and Communication at New York University, tackling debt is just the beginning. ‘This is a way to begin a much wider conversation about what we value in our society,’ he says.‘What we value in people and what we expect a life should be about. We think a life should be about more than just repaying loans, we think people are more than just a loan.’

http://www.newint.org/blog/2012/11/30/strike-debt-personal-debt/

NAIC Senior Issues Task Force rejects cost sharing under Medigap plans

2012 Fall National Meeting

Senior Issues Task Force
National Association of Insurance Commissioners (NAIC), November 30, 2012

Patient Protection and Affordable Care Act
SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP PLANS.
(a) ‘(y) ‘(1) IN GENERAL- The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages described in paragraph (2) under subsection (p)(1), to otherwise update standards to include requirements for nominal cost sharing to encourage the use of appropriate physicians’ services under part B. Such revisions shall be based on evidence published in peer-reviewed journals or current examples used by integrated delivery systems…

11-5-12 Draft of proposed letter from NAIC to HHS Secretary Kathleen Sebelius

(Excerpts of draft)

Pursuant to section 3210 of the Patient Protection and Affordable Care Act (ACA) you have requested the National Association of Insurance Commissioners (NAIC) to review and revise the NAIC Medicare Supplement insurance (Medigap) model regulation to include nominal cost sharing in Medigap Plans C and F to encourage the use of appropriate physicians’ services.

The NAIC has performed its requested review of the standards for Plans C and F under Section 3210 of the ACA.  We were unable to find evidence in peer-reviewed studies or managed care practices that would be the basis of nominal cost sharing designed to encourage the use of appropriate physicians’ services. Therefore, our recommendation is that no nominal cost sharing be introduced to Plans C and F. We hope that you will agree with this determination.
 
Medigap is a product that has served our country’s Medicare eligible consumers well for many years, offering them security and financial predictability with regard to their Medicare costs. Medigap’s protections are now inappropriately being held responsible for encouraging the overuse of covered services and increasing costs in the Medicare program.

The statute requires the NAIC to base nominal cost sharing revisions on “peer-reviewed journals or current examples of integrated delivery systems”. However, the Subgroup discovered that there is a limited amount of relevant peer-reviewed material on this topic. None of the studies provided a basis for the design of nominal cost sharing that would encourage the use of appropriate physicians’ services. Many of the studies caution that added cost sharing would result in delayed treatments that could increase Medicare program costs later (e.g., increased expenditures for emergency room visits and hospitalizations) and result in adverse health outcomes for vulnerable populations (i.e., elderly, chronically ill and low-income).

The Subgroup also gathered information from integrated delivery systems (Medicare Advantage plans) but concluded that, because these managed care plans make medical necessity determinations for Medicare, that any such practices were not directly relevant for Medigap.

In summary, based on our thorough review and deliberation on this topic, we believe, and hope that you will agree, that no changes should be made to Plans C and F to add beneficiary cost sharing at this time.

Respectfully submitted,

http://www.naic.org/documents/committees_b_senior_issues_2012_fall_nm_materials.pdf?1

Comment:

By Don McCanne, MD

From a health policy perspective, this is a big deal. A very big deal! The National Association of Insurance Commissioners (NAIC) is perhaps the most credible and authoritative organization involved with private health insurance. Although this decision by their Senior Issues Task Force is limited to Medigap coverage of Medicare cost sharing, the principles involved challenge the wisdom of trying to control health spending by creating consumer sensitivity to health care prices through deductibles, coinsurance and other forms of cost sharing.

One very fundamental issue with cost sharing is that now we have enough studies to show that there is absolutely no doubt that exposing patients to up-front costs causes many of them to avoid obtaining health care services or products that are beneficial. Cost sharing should be rejected on this basis alone, as the highly flawed policy that it is.

Another crucial point is that the policy community tremendously overestimates the savings that could be achieved by expanding cost sharing. They base their estimates primarily on the findings of the RAND Health Insurance Experiment (RAND HIE). This was a large study of a healthy workforce and their young, healthy families, during a few healthy years of their lives. When they were faced with significant cost sharing they did modestly reduce their use of health care. Obviously that was selective since they would not be parsimonious when it came to disease or injury that threatened life or limb (where most health care spending is).

Since the subjects in the RAND HIE were fundamentally healthy, most of them used little health care during the year and so care forgone because of the cost sharing proved to be a significant percentage of the total spending on their health care. As an example, if $1000 of care were recommended for a person who decided to forgo $300 worth of it but accepted the other $700 worth, then the policy people conclude that cost sharing reduces spending by 30%. They then apply this to total health spending and conclude that we can save 30% of health care costs by requiring deductibles, copayments, and coinsurance.

The defect with this reasoning is that these healthy people consume only a minute fraction of our total health care. The 20% of people with more serious problems consume about 80% of all health care. Because of their serious problems, these people quickly use up their deductibles, and then cost sharing plays only a very minor role. As a percentage of their care received, forgone care rapidly approaches 0%. Thus the percentage savings to the system for this high cost sector is almost negligible.

So the alleged 30% savings applies only to a very small portion of our total health expenditures. Even there, the NAIC conclusion is that forgone care can “result in delayed treatments that could increase Medicare program costs later and result in adverse health outcomes for vulnerable populations.” The NAIC is right to reject this flawed cost sharing policy that saves little and can have serious adverse outcomes. After all, it is the patient that really counts.

Now, as far as the Medigap plans are concerned, they are outrageously overpriced, largely because of their profoundly wasteful administrative excesses. It would be much less expensive to roll the benefits over into the traditional Medicare program. There would be zero extra administrative costs, and even a net reduction since processing the cost sharing has its own administrative costs.

Folding Medigap benefits into Medicare should be a no brainer, especially since it is one of the steps that we want to take in order to improve Medicare as we convert it into a single payer national health program covering all of us – an improved Medicare for all.

NAIC Senior Issues Task Force rejects cost sharing under Medigap plans

2012 Fall National Meeting

Senior Issues Task Force
National Association of Insurance Commissioners (NAIC), November 30, 2012
Patient Protection and Affordable Care Act
SEC. 3210. DEVELOPMENT OF NEW STANDARDS FOR CERTAIN MEDIGAP PLANS.
(a) ‘(y) ‘(1) IN GENERAL- The Secretary shall request the National Association of Insurance Commissioners to review and revise the standards for benefit packages described in paragraph (2) under subsection (p)(1), to otherwise update standards to include requirements for nominal cost sharing to encourage the use of appropriate physicians’ services under part B. Such revisions shall be based on evidence published in peer-reviewed journals or current examples used by integrated delivery systems…
11-5-12 Draft of proposed letter from NAIC to HHS Secretary Kathleen Sebelius
(Excerpts of draft)
Pursuant to section 3210 of the Patient Protection and Affordable Care Act (ACA) you have requested the National Association of Insurance Commissioners (NAIC) to review and revise the NAIC Medicare Supplement insurance (Medigap) model regulation to include nominal cost sharing in Medigap Plans C and F to encourage the use of appropriate physicians’ services.
The NAIC has performed its requested review of the standards for Plans C and F under Section 3210 of the ACA.  We were unable to find evidence in peer-reviewed studies or managed care practices that would be the basis of nominal cost sharing designed to encourage the use of appropriate physicians’ services. Therefore, our recommendation is that no nominal cost sharing be introduced to Plans C and F. We hope that you will agree with this determination.
Medigap is a product that has served our country’s Medicare eligible consumers well for many years, offering them security and financial predictability with regard to their Medicare costs. Medigap’s protections are now inappropriately being held responsible for encouraging the overuse of covered services and increasing costs in the Medicare program.
The statute requires the NAIC to base nominal cost sharing revisions on “peer-reviewed journals or current examples of integrated delivery systems”. However, the Subgroup discovered that there is a limited amount of relevant peer-reviewed material on this topic. None of the studies provided a basis for the design of nominal cost sharing that would encourage the use of appropriate physicians’ services. Many of the studies caution that added cost sharing would result in delayed treatments that could increase Medicare program costs later (e.g., increased expenditures for emergency room visits and hospitalizations) and result in adverse health outcomes for vulnerable populations (i.e., elderly, chronically ill and low-income).
The Subgroup also gathered information from integrated delivery systems (Medicare Advantage plans) but concluded that, because these managed care plans make medical necessity determinations for Medicare, that any such practices were not directly relevant for Medigap.
In summary, based on our thorough review and deliberation on this topic, we believe, and hope that you will agree, that no changes should be made to Plans C and F to add beneficiary cost sharing at this time.
Respectfully submitted,
http://www.naic.org/documents/committees_b_senior_issues_2012_fall_nm_ma…

From a health policy perspective, this is a big deal. A very big deal! The National Association of Insurance Commissioners (NAIC) is perhaps the most credible and authoritative organization involved with private health insurance. Although this decision by their Senior Issues Task Force is limited to Medigap coverage of Medicare cost sharing, the principles involved challenge the wisdom of trying to control health spending by creating consumer sensitivity to health care prices through deductibles, coinsurance and other forms of cost sharing.
One very fundamental issue with cost sharing is that now we have enough studies to show that there is absolutely no doubt that exposing patients to up-front costs causes many of them to avoid obtaining health care services or products that are beneficial. Cost sharing should be rejected on this basis alone, as the highly flawed policy that it is.
Another crucial point is that the policy community tremendously overestimates the savings that could be achieved by expanding cost sharing. They base their estimates primarily on the findings of the RAND Health Insurance Experiment (RAND HIE). This was a large study of a healthy workforce and their young, healthy families, during a few healthy years of their lives. When they were faced with significant cost sharing they did modestly reduce their use of health care. Obviously that was selective since they would not be parsimonious when it came to disease or injury that threatened life or limb (where most health care spending is).
Since the subjects in the RAND HIE were fundamentally healthy, most of them used little health care during the year and so care forgone because of the cost sharing proved to be a significant percentage of the total spending on their health care. As an example, if $1000 of care were recommended for a person who decided to forgo $300 worth of it but accepted the other $700 worth, then the policy people conclude that cost sharing reduces spending by 30%. They then apply this to total health spending and conclude that we can save 30% of health care costs by requiring deductibles, copayments, and coinsurance.
The defect with this reasoning is that these healthy people consume only a minute fraction of our total health care. The 20% of people with more serious problems consume about 80% of all health care. Because of their serious problems, these people quickly use up their deductibles, and then cost sharing plays only a very minor role. As a percentage of their care received, forgone care rapidly approaches 0%. Thus the percentage savings to the system for this high cost sector is almost negligible.
So the alleged 30% savings applies only to a very small portion of our total health expenditures. Even there, the NAIC conclusion is that forgone care can “result in delayed treatments that could increase Medicare program costs later and result in adverse health outcomes for vulnerable populations.” The NAIC is right to reject this flawed cost sharing policy that saves little and can have serious adverse outcomes. After all, it is the patient that really counts.
Now, as far as the Medigap plans are concerned, they are outrageously overpriced, largely because of their profoundly wasteful administrative excesses. It would be much less expensive to roll the benefits over into the traditional Medicare program. There would be zero extra administrative costs, and even a net reduction since processing the cost sharing has its own administrative costs.
Folding Medigap benefits into Medicare should be a no brainer, especially since it is one of the steps that we want to take in order to improve Medicare as we convert it into a single payer national health program covering all of us – an improved Medicare for all.