PNHP

Universal health care and the Iron Triangle myth of U.S. policy makers

Universal health care and the Iron Triangle myth of U.S. policy makers

Donald Light on the Iron Triangle Myth

By Donald Light

Response to the October 4, 2012 Quote of the Day on the meme of access, cost and quality (https://pnhp.org/news/2012/october/aaron-carroll-repeats-meme-of-access-cost-and-quality):

In my comparative studies of universal health care systems, I find their cost/quality profiles vary quite a bit between each other, and over time for the following reasons. The more such systems pay by fee, the more providers drive up costs in the name of “quality” from which they profit, such as Germany from after World War II up to the 1980s. The Canadian system has been suffering from this seeming trade-off for decades. Access stays universal but there seems to be “an iron trade-off” between cost and quality, until systems start moving towards bundled payments and then population-based capitation or salary within a national health service and an ethos of shared responsibility to improve quality within a fixed budget. (Notice the so-called “iron triangle” has faded from view.)

Thus it’s holding costs constant while maintaining universal access that is key to improving quality, not only by eliminating care that is detrimental but also unnecessary or avoidable care, by rethinking clinical strategies. Ironically, some of the models of shared access and budgets increasing quality are in the United States. Few, if any national systems, can match the steady improvements in quality and value of Kaiser Permanente, Intermountain, Marshfield, or the reformed VHA (Veterans Health Administration). For example, the English NHS has been learning from them for years.

The transformation of the VHA from a single-payer, fee-based, poor-quality set of hospital-centered services, to a single-payer system based on area population budgets centered on primary care, with coordinated, community-based specialty back-up and hospitals as a last resort offers inspiring lessons. Quality improved and costs sharply dropped, so that 30 percent more veterans could be treated within the same, fixed budget.

Reforms in Germany in the 1990s through today have also improved quality while lowering relative costs and expanding access from about 94 percent to 99 percent. Germany’s multi-insurer base has been made single payer-like by the government creating a single channel where all insurers’ premiums are risk-adjusted so all insurers operate on the same risk-adjusted budgetary basis. The Dutch reforms since 2006 operate in a similar way, with some distinct differences.

In sum, I would say the key is not single-payer per se but population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames that give the lie to the so-called iron triangle.

The Iron Triangle is an American myth for lazy and unobservant policy leaders.

Donald W. Light, Ph.D.
Professor, UMDNJ-SOM
Visiting Researcher, Center for Migration & Development, Princeton University
Resident Fellow, Edmond J. Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania

Comment:

By Don McCanne, MD

As Professor Light shows us, with controlled budgets you can still improve quality in a system that ensures appropriate access for everyone. Although he states that the key is not single payer per se, it is clear that the Iron Triangle (interdependency of cost, quality and access) still applies to our fragmented, dysfunctional financing system in the United States – a system that has only been perpetuated with the Affordable Care Act. However, social insurance programs, including single payer and health service models, have shown that the inevitability of the Iron Triangle is a myth. An improved Medicare for all would provide us with “population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames.”

Conversations with … Quentin Young, MD

By George Lundberg, M.D.
MedPage Today

Transcript:

GEORGE LUNDBERG, M.D.: Hello, and welcome. I’m Dr. George Lundberg, editor-at-large for MedPage Today, and we are in Chicago taking an opportunity to have a conversation with a famous name: Dr. Quentin Young. Dr. Young, thank you so much for being with us.

QUENTIN YOUNG, M.D.: It’s a pleasure.

LUNDBERG: Dr. Young has been a practicing internist at Hyde Park for many decades. At one time, he was chairman of the Department of Medicine at the Cook County Hospital.

YOUNG: Yes.

LUNDBERG: I believe he’s been an AMA member since 1952.

YOUNG: Exactly.

LUNDBERG: Something like that. In other words, he was once the president of the American Public Health Association. But for the past couple of decades, or maybe 25 years, he’s been best identified as a physician leader for the United States on trying to get basic health care for all Americans, preferably through a single payer type system. His organization is called Physicians for National Health Policy.

YOUNG: Well, that’s a very generous introduction. It’s actually National Health Program, but the “P” is …

LUNDBERG: National Health Program, all right. Say it right.

YOUNG: Physicians for a National Health Program.

LUNDBERG: There you go.

YOUNG: And what’s interesting in my professional lifetime and yours, physicians have become, in this issue, much more liberal. They used to think of the government as the really huge enemy. Now they’ve found something worse than government: Corporations.

LUNDBERG: But why hasn’t the single payer movement, which I have always opposed the name — I think it should be “main payer.”

YOUNG: Okay.

LUNDBERG: Rather than “single,” because Americans hate monopoly.

YOUNG: Yes.

LUNDBERG: They want to have an escape valve of some sort.

YOUNG: Yes.

LUNDBERG: But anyway, despite the fact that Medicare gets very high ratings from patients and many doctors now, and the surveys of physicians …

YOUNG: Yes.

LUNDBERG: …are moving more and more towards the idea of a single payer. But it doesn’t have traction with the government or with the Congress. What’s wrong?

YOUNG: Well, as the power of corporate sector, 20 years at the most, there was no organized corporate medical delivery system, but this was a huge profit center, and for the last 20 years, we’ve seen the disappearance of private practice. And, yes, my colleagues in the medical profession, conservative as they are, have finally found something they hate worse than government, and it is the corporations. They lose the autonomy, which is really, as you well know, really central to the whole medical care transactions.

LUNDBERG: So physicians in America, many of them are unhappy.

YOUNG: To say the least. And while their income isn’t that bad, and we have to be honest about that, their autonomy is. And the domination of the system in the best sense, where doctors made the decisions in collaboration with their patients, that’s almost all gone. And another decade and we’ll have a corporate system with huge salaries and rewards at the top, and people, ordinary doctors and people at the bottom will have a hard time getting decent care.

LUNDBERG: But are you suggesting that in a Medicare-for-all type approach, physicians would have more autonomy?

YOUNG: I think so. It’s not guaranteed. We physicians will always have to assert our autonomy. But that’s what good medical systems are, based on doctors’ capacity to take the facts, interview the patient, and come up with the best answer. It’s a real paradox. Patients really like the medical profession, they trust their doctors, and yet doctors have lost a huge amount of their autonomy; they really don’t have control of the system. And that’s one of the items that we think is going to make national health insurance possible.

LUNDBERG: Well, when we’re having this conversation, we’re all waiting for the Supreme Court to issue its determination.

YOUNG: That’s right.

LUNDBERG: About the constitutionality, or the political acceptability, in some ways, of the Affordable Care Act. We don’t know how it’s going to shake out. What do you think?

YOUNG: Well, for the first time in my life, I think I don’t have the answer. There are two possibilities, they’re quite opposite, and either one could happen. I think the Supreme Court is divided four and four, liberal/conservative, and with Justice Kennedy having the swing vote. And from the preliminary interviews where he heard the arguments on both sides, he seemed like he was inclined toward outlawing the present bill, and I’m no legal expert obviously, but I think he may be right. And as soon as you take the Affordable Care Act off the table because you deem it unconstitutional, you have only two alternatives at marketplace, which is a fiasco, and also single-payer, or, as you would have it, Medicare-for-all.

LUNDBERG: So you would see an overturn of the Affordable Care Act as an opportunity for your movement.

YOUNG: Well, we certainly don’t vie for it, and we don’t have near the political power that would make it happen, but the answer is Yes. I think as soon as they rule, if they rule it unconstitutional, then they have to have an answer. You know very well, you’ve probably said many times, we spent twice as much per capita for our health care with 50 million people out of the loop; that’s ridiculous. And the health care economy is threatening the larger economies, coming to 18 percent of the gross domestic product, and I think we have to fix it fast or our nationhood supremacy is going to go in decline. I really feel that way.

LUNDBERG: I believe almost everybody now agrees with that point of view. I’ve been talking about the excess costs of medical and health care for 25 years probably, but it just keeps going up. But now I believe most people agree with the notion that it’s too expensive. If the court were to say only the …

YOUNG: Mandate.

LUNDBERG: … individual mandate was unconstitutional, the rest went forward, would this be an opportunity to put the public option back on the table?

YOUNG: I think so. There are different states approaching this; some are well along the way. Vermont comes to mind, Hawaii, California, for that matter. But on the other hand, there are many states that are in the clutches of very conservative forces, and in my mind, in the clutches of the corporate sector, and it’s really an abomination. As you know, I’ve been a doctor for some 60 years and enjoyed the entire run, but they’re making it very hard for patients to get the benefits of modern medical science, and the public is learning about it. I think they’re discouraged that they get sick and … actual finding themselves in a dreadful circumstance with bankruptcy as an alternative.

LUNDBERG: Right. I think one of the good things about the Affordable Care Act and all the discussions about it is that a great number of the public have learned a lot more about the system — its faults, its frailties, its difficulties — from the education of the discussion of this, even though the discussion about it has been largely partisan and sometimes filled with faulty information. Nonetheless, there’s been a lot of education about it.

YOUNG: Well, certainly, and it’s born out of necessity. People need health care at one point or another.

LUNDBERG: Of course.

YOUNG: When they’re born or when they’re late in life. But the system is not working; it’s not responsive. I’ve been in practi
ce since World War II, and I saw it, in my eyes, how the confidence and attraction of the health care service — what we doctors gave — slowly went away and became a medical anomaly and became very, very hard for people to get decent care.

And as the triumphs of medicine work against it, people are living longer, meaning they have more years to be ill.

So we have a very crucial fight. And I’m active in the Physicians for a National Program, as you’ve pointed out, and this is my valedictory. I’m pretty old, and I had to have some way, at the end of my life, and I’ve chose national health insurance. It’s going to be hard, because the opponents are extremely wealthy, extremely capable of resisting real reform, but I think it’s the only solution. And I don’t mean for the health system; for the economy. We can’t tolerate the kind of exorbitant costs associated with the present system.

And we think, and we feel it, that the public doctors on one hand and the general public as patients on the other have come to believe that the only way to get out of this mess is to join the rest of the world, and that’s worth noting. All of the other countries that resemble us, you know, that have an industrialized and capitalist kind of system, have all chosen to have a national health service, and they all do better. They have longer life expectancies. They have freedom from diseases that are preventable. It’s just something we shouldn’t put up with.

LUNDBERG: Right. Well, thank you very much, Dr. Quentin Young, for being with us today. Thank you for your lifetime of dedicated service to individual patients and trying to make things better for all people in the United States. We’ll all see what happens and look forward to further reactions.

YOUNG: Exactly.

LUNDBERG: Thank you for being with us. I’m Dr. George Lundberg, at large for MedPage Today.

Dr. George Lundberg is editor-at-large at MedPage Today.

http://www.medpagetoday.com/PublicHealthPolicy/GeneralProfessionalIssues/35173

Post-election deficit deal threatens Medicare and Social Security

The solution is Improved Medicare for All

By Kay Tillow
Firedoglake, Oct. 6, 2012

After the November election, there will be a major effort in Congress to pass a budget deal that will make cuts in Social Security, raise the Medicare and Social Security eligibility age, and perhaps more – unless we act to stop it with a solution that is close at hand.

There is agreement from the Wall Street Journal’s David Wessel to liberal economists Dean Baker and Paul Krugman that the pressure will be on to reach a Simpson/Bowles type of compromise. Such a bipartisan plan would damage our most cherished programs and excuse the dastardly deed by asserting that the cuts are small and necessary because of the deficit.

Those who relentlessly scream at us and finance ads to persuade us that the deficit threatens our grandchildren are obscuring the truth. The fact is that the transfer of wealth from public funds and the rest of us to the super rich is the real crisis. But those who have gorged themselves on this massive transfer of wealth also seek to undermine the Medicare and Social Security which are our grandchildren’s heritage from generations of struggles for a better life.

The projected cuts are not minor but very harmful. Even a small decrease in the Social Security Cost-of-Living Adjustment would deliver an ever increasing downward push on benefits while corporations continue to threaten secure pensions by turning them into lump sums that will fade with the stock market.

Raising the Medicare age to 67 would be disastrous. There will be no affordable health insurance for those in their 60s. The Affordable Care Act allows private insurance companies to charge premiums three times higher based on age. Under popular pressure, there were regulations placed into the health care reform bill to stop insurance companies from charging higher premiums based on pre-existing conditions. But the companies were allowed to charge three times the premium based on age.

Because of this allowed age discrimination, the Kaiser Foundation estimates that an individual of age 60 in 2014 with an annual income of $50,000 will pay a health insurance premium of over $10,000, or over 20 percent of income. That does not include out-of-pocket costs which can add up to an additional $6,000 annually. That brings the total to 32 percent of income — a bankrupting figure.

There is a solution that the single-payer movement must place on the nation’s table. Even Bill Clinton said that we could save $1 trillion a year if we adopted the health care system of any of the other developed countries in the world. No more stewing over the deficit!

An Expanded and Improved Medicare for All, H.R. 676, would save Medicare, end the uncontrolled, gargantuan rise in all health care costs, ease the deficit pressure, and actually bring universal health care to the nation.

This single-payer legislation, H.R. 676, introduced by Congressman John Conyers and co-sponsored by 76 representatives, would divert $400 billion annually from profits and waste generated by the private health insurance industry into care for all. Care would be expanded and costs bought under control through bulk purchasing, global budgeting, and the elimination of administrative expenses forced upon our system in the pursuit of profit.

Doctors would be freed from insurance industry interference with care. Patients would be freed to choose their physicians. Dental, eyeglasses, hearing aids, prescription drugs, long-term care, doctors, hospitals, home health, mental health — all medically necessary care would be included. Our health care costs would stop driving us over the cliff and level off just as Canada’s did when that country fully implemented their single-payer health care.

Co-pays and deductibles would be banned, ending today’s growing problem that health insurance policies are so miserly that even the insured forgo care because they can’t afford it.

Our country spends about twice per capita what other industrialized nations spend on health care, yet our health care system lags far behind at number 37 in the world.

So why are we even debating cuts to Medicare, Social Security and Medicaid when the solution is at hand that would bring us both better care and cost controls? H.R. 676, an improved Medicare for All, is sitting in the Congress, awaiting the rising of a movement that will insist upon its passage.

Kay Tillow is coordinator of the All Unions Committee for Single Payer Health Care, which builds union support for H.R. 676. She lives in Louisville, Ky., where she is also an activist with Kentuckians for Single Payer Health Care.

http://my.firedoglake.com/kaytillow/2012/10/06/post-election-deficit-deal-threatens-medicare-and-social-security/

Universal health care and the Iron Triangle myth of U.S. policy makers

Donald Light on the Iron Triangle Myth

By Donald Light
Response to the October 4, 2012 Quote of the Day on the meme of access, cost and quality (https://pnhp.org/news/2012/october/aaron-carroll-repeats-meme-of-acce…):
In my comparative studies of universal health care systems, I find their cost/quality profiles vary quite a bit between each other, and over time for the following reasons. The more such systems pay by fee, the more providers drive up costs in the name of “quality” from which they profit, such as Germany from after World War II up to the 1980s. The Canadian system has been suffering from this seeming trade-off for decades. Access stays universal but there seems to be “an iron trade-off” between cost and quality, until systems start moving towards bundled payments and then population-based capitation or salary within a national health service and an ethos of shared responsibility to improve quality within a fixed budget. (Notice the so-called “iron triangle” has faded from view.)
Thus it’s holding costs constant while maintaining universal access that is key to improving quality, not only by eliminating care that is detrimental but also unnecessary or avoidable care, by rethinking clinical strategies. Ironically, some of the models of shared access and budgets increasing quality are in the United States. Few, if any national systems, can match the steady improvements in quality and value of Kaiser Permanente, Intermountain, Marshfield, or the reformed VHA (Veterans Health Administration). For example, the English NHS has been learning from them for years.
The transformation of the VHA from a single-payer, fee-based, poor-quality set of hospital-centered services, to a single-payer system based on area population budgets centered on primary care, with coordinated, community-based specialty back-up and hospitals as a last resort offers inspiring lessons. Quality improved and costs sharply dropped, so that 30 percent more veterans could be treated within the same, fixed budget.
Reforms in Germany in the 1990s through today have also improved quality while lowering relative costs and expanding access from about 94 percent to 99 percent. Germany’s multi-insurer base has been made single payer-like by the government creating a single channel where all insurers’ premiums are risk-adjusted so all insurers operate on the same risk-adjusted budgetary basis. The Dutch reforms since 2006 operate in a similar way, with some distinct differences.
In sum, I would say the key is not single-payer per se but population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames that give the lie to the so-called iron triangle.
The Iron Triangle is an American myth for lazy and unobservant policy leaders.
Donald W. Light, Ph.D.
Professor, UMDNJ-SOM
Visiting Researcher, Center for Migration & Development, Princeton University
Resident Fellow, Edmond J. Safra Center for Ethics, Harvard University
Senior Fellow, Center for Bioethics, University of Pennsylvania

 
As Professor Light shows us, with controlled budgets you can still improve quality in a system that ensures appropriate access for everyone. Although he states that the key is not single payer per se, it is clear that the Iron Triangle (interdependency of cost, quality and access) still applies to our fragmented, dysfunctional financing system in the United States – a system that has only been perpetuated with the Affordable Care Act. However, social insurance programs, including single payer and health service models, have shown that the inevitability of the Iron Triangle is a myth. An improved Medicare for all would provide us with “population-based budgeting together with universal access, and a shared ethos to improve quality within budgetary frames.”

Health reform and professional ethics

By Stephen B. Kemble, M.D.

PNHP note: The following is the inaugural address that Dr. Kemble, president of the Hawaii Medical Association and single-payer advocate, delivered to the HMA at its annual Ola Pono Ike (“Health is Knowledge”) assembly on Oct. 6, 2012.

I have been thrust into HMA leadership based on my advocacy for universal health care. Although single-payer health care financing is not AMA policy, I want to thank all of you who have supported me in advocating for truly cost-effective, universal health care that puts the needs of our patients first, in keeping with the highest tradition of professional medical ethics. I also want to thank my family and friends for putting up with my obsessive preoccupation with health care reform over the past 5 years, and with all the time that has gone into what I refer to as “community service,” sometimes at the expense of time for family and for my psychiatric practice.

Much of the national discussion and policy initiatives on health care reform have been based on the assumption that runaway health care costs are due to “too much care,” either instigated by doctors due to fee-for-service incentives, or instigated by patients who want to “consume” too much care because it is covered by insurance. The assumption that we are delivering too much care is driving efforts to reform physician payment away from fee-for-service and towards pay-for-performance, pay-for-outcomes, bundled payments, capitation, and related schemes intended to counter the supposed incentive under fee-for-service to provide too much care. “Too much care” is also the rationale for increasing cost sharing for patients in the form of higher deductibles and co-payments. However, the beliefs that our health care cost problems are due to “the fee-for-service treadmill” and to patients demanding too much care are fundamental misdiagnoses of the problem. Inadequate access to necessary and appropriate care is a much bigger problem in the US than excessive care.1

If fee-for-service were a root cause of runaway health costs, then how are other countries that use fee-for-service payment of doctors able to cover everyone and spend 50-60% of what we do per capita on health care? These other countries include Canada, Australia, New Zealand, Taiwan, Japan, Germany, France, Switzerland, Israel, and many others. Much of the evidence for a large amount of unnecessary care in the US is based on studies of regional variation in Medicare spending2, but if this is due to fee-for-service, then how do we explain the fact that high and low spending regions use fee-for-service equally?

Although some “worried well” patients may be deterred from seeking unnecessary care by increased cost sharing, these patients account for only a tiny fraction of total health expenditures. For the seriously or chronically ill who account for 80-90% of health care spending, increased cost sharing deters necessary and beneficial care and has been shown in studies to increase total health care costs, especially for the poor and elderly who are the highest risk populations.3,4

So what is causing US health care to cost so much? There is plenty of evidence that administrative complexity is a large part of the problem.5,6 This is due to fragmentation of US health care and use of competing health plans to finance health care, whether private health insurance plans provided through employment, or privatized government-funded programs such as Medicaid managed care, Medicare Advantage, and Medicare Part D.

In my opinion, another major factor is the de-professionalization of doctors. There are two broad ethical paradigms in the world of economics: commercial ethics and “guardian” ethics. The commercial paradigm assumes a seller and buyer of goods or services, whose power and interests are balanced through the marketplace and the laws of supply and demand, with financial incentives as a primary motivator. Guardian ethics are applicable to socially necessary services that require specialized training and expertise not available or achievable by the general public, so that there is an inherent imbalance of power between the provider and recipient of services. Classic examples are the military, medicine, and other specialized professions. In these cases, the interests of the public are protected by a tradition of professionalism and concern for the welfare of the public, or patient, or client, which is held to be a higher ethical value than financial considerations.7

There has been a movement in this country for the past 50 years to de-professionalize medicine, with an underlying assumption that commercial ethics are the only valid and trustworthy ethics. This justifies increasing interference in health care decisions by hospitals, insurance plans, and government, and an over-reliance on financial incentives to “fix” problems in health care, and especially its high cost.

Medical students start their training with the Hippocratic oath and with an idealistic desire to help others. However, they are often burdened with exorbitant debt, and they discover that half their time is spent “treating the chart” so that the hospital or clinic where they are working can get paid. These problems are compounded by payment reform initiatives that rely on financial incentives, supposedly intended to “improve” care, such as diagnosis related groups (DRG’s), pay-for-performance, pay-for-outcomes, and denial of payment for adverse events. These strategies add administrative burdens and generally fail to account for the difficulties in accurately defining “quality” or “outcomes” due to the complexity of health care.

Unfortunately, if doctors are stripped of their professional autonomy and treated as if financial considerations are paramount, they actually do start to abandon professional ethics for commercial ones. They start responding to financial considerations above patient needs; they select patients according to their insurance status; they try to avoid taking on sicker, more complex patients, and they look for ways to game the system or to make more money from things other than professional services. They begin to try to maximize income by any available means, helping drive the cost of health care higher. Sometimes this leads to outright fraud.

If these de-professionalizing forces are combined with fee-for-service, then we do indeed get unnecessary and inappropriate care. Insurance plans and government agencies then double down on monitoring documentation to look for fraud and abuse and try to develop financial incentives to deter unnecessary care. The result is a vicious cycle of escalating administrative burdens, declining access to care for patients who need it, and a demoralized physician work force8. This is exactly what we are now experiencing!

In the effort to slow the escalation in health care costs, whose ox will get gored? Will it be doctors and hospitals, in the form of rising administrative burdens and declining pay? Will it be patients, in the form of increased cost sharing, most of which is not affordable for those with significant health problems, and in declining access to needed care? Or will it be the insurance industry? Only one of these is not an integral part of health care, and the explosion in health care costs in the US is largely on their side of the ledger. However, the insurance industry does not want to be pushed out of health care and they have accumulated a lot of money to protect their interests, hence the focus on blaming doctors and patients for rising costs.

What are the solutions?
1.  Although health care does require some administrative functions, we need to minimize the role of competing insurance plans in managing delivery of care. This can be accomplished by developing a unified delivery system for a State or region in which all doctors and hospitals i
n a community participate, with standardized benefits and payment for providers, so that they are paid the same regardless of the source of funding for an individual patient. This is called an “all-payer” system, with a unified delivery system even if there are several sources of funding.
2.  We need public subsidies for medical education in exchange for practicing in underserved specialties and locations, as is being initiated here in Hawaii in the form of a new Hawaii State Loan Repayment program.
3.  We need to ensure the cost-effectiveness of care with physician-led quality improvement instead of insurance-driven managed care. Financial incentives such as pay-for-outcomes, bundled payments, and capitation of doctors ignore the complexities of health care and introduce perverse incentives to avoid treating sicker, more complex patients. They should have no place in quality improvement. A far better approach is William Demings’s Continuous Quality Improvement model, as has been demonstrated in auto manufacturing, airline safety, and in health care in some US communities, such as Intermountain Health Care in Utah, Rocky Mountain Health Plans in Western Colorado, and Community Care of North Carolina.9,10,11 With Continuous Quality Improvement all errors and quality problems are viewed as system problems, instead of looking for individuals to blame and punish. Everyone involved in health care is enlisted in sharing information and ideas to solve problems and improve delivery of care. Blaming individual doctors and hospitals, whether through individual sanctions or individualized performance and quality ratings tied to financial rewards and penalties, drives everyone into gaming documentation, and when there is an error, into silence and the arms of the attorneys, preventing effective improvement of care.
4.  We need to organize doctors for quality improvement. Physician-directed quality improvement requires organization, sharing of information necessary to improve quality, and a mechanism for shared savings from improving care. The alternative to organization of physicians is more managed care administered by insurance plans and government, and the continued de-professionalization of doctors.
5.  Quality improvement and efforts to make care more cost effective should not be based primarily on financial incentives, but must be rooted in professional ethics and in the goal of meeting the health care needs of both individual patients and population health.
6.  Instead of the complexities of the Resource Based Relative Value Scale and Evaluation and Management procedure codes, let’s simply pay doctors for their time, with a multiplier for training and practice costs.12 Separate quality incentives may be appropriate, but must be in proportion to those components of health care that can be accurately and meaningfully measured, and these are probably only about a quarter of health care due to its complexity. Specialties requiring more training and overhead would be paid at a higher hourly rate, but for each individual doctor this rate would be the same regardless of the activity or procedure being performed. Time for care coordination should be included in reimbursement. This would greatly reduce the complexities required by “pay-for-documentation” and it would allow documentation to be re-focused on patient care and quality improvement instead of reimbursement. If payment were task-neutral, then there would be no preferential incentive to do procedures instead of things like talking to patients and obtaining a good history and thorough physical exam. The primary incentive for physicians would then be to simply use their time and skills, to the best of their ability as professionals, to serve the health care needs of their patients.
7.  Above all, we need to place the best interests of our patients at the center of health care again.

Thank you.
 
REFERENCES:

1.  Elizabeth A. McGlynn et al., The quality of health care delivered to adults in the United States. N Engl J Med. 2003;348:2635-2645, 2641.
2.  Fisher ES, Bynum JP, Skinner JS. Slowing the Growth of Health Care Costs – Lessons From Regional Variation. N Engl J Med. 2009 Feb 26;360(9):849-52.
3.  M. Gregg Bloche. Consumer-Directed Health Care And The Disadvantaged. Health Affairs, 26, no.5 (2007):1315-1327
4.  Trivedi AN, Husein Moloo, Mor V. Increased Ambulatory Care Copayments and Hospitalizations among the Elderly. N Engl J Med. 2010;362:320-8.
5.  Blanchfield BB, Heffernan JL, Osgood B, Sheehan RR , Meyer GS.
Saving Billions Of Dollars−−And Physicians’ Time−−By Streamlining Billing Practices. Health Affairs 29,
No. 6 (2010): 1248–1254
6.  Morra D, Nicholson S, Levinson W, Gans DN, Hammons T, Casalino LP. US Physician Practices vs. Canadians: Spending Nearly Four Times as Much Money Interacting With Payers. Health Affairs 30 , No. 8 (2011): doi: 10.1377/hlthaff.2010.0893.
7.  Jacobs J. Systems of Survival: A Dialogue on the Moral Foundations of Commerce and Politics. New York: Random House; 1992
8.  Chen P. The Widespread Problem of Doctor Burnout. New York Times. Aug 23, 2012.
9.  James BC and Savitzdoi LA. How Intermountain Trimmed Health Care Costs Through Robust Quality Improvement Efforts. Health Affairs 30, no. 6 (2011); DOI:10.1377/hlthaff.2011.0358
10.  Bodenheimer, T, West D. Low-Cost Lessons from Grand Junction, Colorado. N Eng J Med 2010; DOI:10.1056/NEJMp1008450.
11.  Community Care of North Carolina: Putting Health Reform Ideas into Practice in Medicaid. The Kaiser Family Foundation Publication #7899, May 2009. (http://www.kff.org/medicaid/7899.cfm)
12.  Wachtel TJ, Stein MD. Fee-for-Time System: A Conceptual Framework for an Incentive-Neutral Method of Physician Payment. JAMA 1993;270(10):1226-1229

Physicians' Presidential Poll

Results of the 2012 Physicians' Presidential Poll

By Jackson & Coker Research Associates
Jackson & Coker Industry Report, October 1, 2012

A new survey of physicians shows that if the Presidential election were held today, 55 percent would vote for Mitt Romney and 36 percent would support President Obama, according to a survey conducted by Jackson & Coker, a division of Jackson Healthcare, the third largest healthcare staffing company in the US.

When asked how they felt about the Affordable Care Act, 55 percent said “repeal and replace” the new law while 40 percent said “implement and improve” the ACA.

http://www.jacksoncoker.com/physician-career-resources/newsletters/monthlymain/des/PresidentialPoll.aspx

Comment:

By Don McCanne, MD

Rather than demonstrating where physicians are on their beliefs and understanding of health policy, this poll merely shows that the debate has been reduced to the politics of the Affordable Care Act (ACA). Of the 55 percent who would replace ACA, there is no breakdown on those who would replace it with Medicare for All (neither candidate)  and those who would replace it with policies that likely would shift more of the financial burden to patients (Romney). Also, of the 40 percent who would improve ACA there is no breakdown of those who would support the dubious strategy of modifying it incrementally as a means of eventually achieving single payer reform (neither candidate). We need surveys of physicians’ views on policy, not politics.

Physicians’ Presidential Poll

Results of the 2012 Physicians’ Presidential Poll

By Jackson & Coker Research Associates
Jackson & Coker Industry Report, October 1, 2012

A new survey of physicians shows that if the Presidential election were held today, 55 percent would vote for Mitt Romney and 36 percent would support President Obama, according to a survey conducted by Jackson & Coker, a division of Jackson Healthcare, the third largest healthcare staffing company in the US.

When asked how they felt about the Affordable Care Act, 55 percent said “repeal and replace” the new law while 40 percent said “implement and improve” the ACA.

http://www.jacksoncoker.com/physician-career-resources/newsletters/monthlymain/des/PresidentialPoll.aspx

Comment:

By Don McCanne, MD

Rather than demonstrating where physicians are on their beliefs and understanding of health policy, this poll merely shows that the debate has been reduced to the politics of the Affordable Care Act (ACA). Of the 55 percent who would replace ACA, there is no breakdown on those who would replace it with Medicare for All (neither candidate)  and those who would replace it with policies that likely would shift more of the financial burden to patients (Romney). Also, of the 40 percent who would improve ACA there is no breakdown of those who would support the dubious strategy of modifying it incrementally as a means of eventually achieving single payer reform (neither candidate). We need surveys of physicians’ views on policy, not politics.

Physicians' Presidential Poll

Results of the 2012 Physicians’ Presidential Poll

By Jackson & Coker Research Associates
Jackson & Coker Industry Report, October 1, 2012
A new survey of physicians shows that if the Presidential election were held today, 55 percent would vote for Mitt Romney and 36 percent would support President Obama, according to a survey conducted by Jackson & Coker, a division of Jackson Healthcare, the third largest healthcare staffing company in the US.
When asked how they felt about the Affordable Care Act, 55 percent said “repeal and replace” the new law while 40 percent said “implement and improve” the ACA.
http://www.jacksoncoker.com/physician-career-resources/newsletters/month…

Rather than demonstrating where physicians are on their beliefs and understanding of health policy, this poll merely shows that the debate has been reduced to the politics of the Affordable Care Act (ACA). Of the 55 percent who would replace ACA, there is no breakdown on those who would replace it with Medicare for All (neither candidate)  and those who would replace it with policies that likely would shift more of the financial burden to patients (Romney). Also, of the 40 percent who would improve ACA there is no breakdown of those who would support the dubious strategy of modifying it incrementally as a means of eventually achieving single payer reform (neither candidate). We need surveys of physicians’ views on policy, not politics.

Aaron Carroll repeats meme of access, cost and quality

JAMA Forum — The “Iron Triangle” of Health Care: Access, Cost, and Quality

By Aaron Carroll, MD, MS
news@JAMA, October 3, 2012

When I talk about health policy, I often refer to the iron triangle of health care. The 3 components of the triangle are access, cost, and quality. One of my professors in medical school used this concept to illustrate the inherent trade-offs in health care systems. His point was that at any time, you can improve 1 or perhaps even 2 of these things, but it had to come at the expense of the third.

I can make the health care system cheaper (improve cost), but that can happen only if I reduce access in some way or reduce quality. I can improve quality, but that will either result in increased costs or reduced access. And of course, I can increase access—as the Affordable Care Act (ACA) does—but that will either cost a lot of money (it does) or result in reduced quality.

Anyone who tells you that he or she can make the health care system more universal, improve quality, and also reduce costs is in denial or misleading you.

We can make the system cheaper. We can make it more expansive. We can make it higher in quality. But we can’t do all 3.

http://newsatjama.jama.com/2012/10/03/jama-forum-the-iron-triangle-of-health-care-access-cost-and-quality/

Comment:

By Don McCanne, MD

We have heard for decades the meme that health care access, cost and quality are interdependent. Any change in one or two of them must produce a reciprocal change in either one or both of the others. Any improvement must always be offset with one or two impairments. Yet the single payer model shows that this is merely a replication of a seriously deficient concept that omits consideration of many other important health policies.

Under a properly designed single payer model, access is improved by removing financial barriers to care for absolutely everyone. The comprehensive design features of single payer also significantly improve quality, simply stated, by ensuring that patients receive the care that they need while reducing or eliminating care that is detrimental. And costs are the forte of the single payer system. Single payer reduces waste, redirecting those funds to patient care, and puts into place economic mechanisms that slow the rate of increase in future health care costs. Spending can be contained while both quality and access are improved.

It is time to retire the meme that improving access, costs or quality can be done only by introducing impairments. Don’t let the policy community get away with that claim anymore. Aaron Carroll’s integrity is of such a high caliber that he certainly is not misleading us, but he clearly needs to end his denial.

Aaron Carroll repeats meme of access, cost and quality

JAMA Forum — The “Iron Triangle” of Health Care: Access, Cost, and Quality

By Aaron Carroll, MD, MS
news@JAMA, October 3, 2012
When I talk about health policy, I often refer to the iron triangle of health care. The 3 components of the triangle are access, cost, and quality. One of my professors in medical school used this concept to illustrate the inherent trade-offs in health care systems. His point was that at any time, you can improve 1 or perhaps even 2 of these things, but it had to come at the expense of the third.
I can make the health care system cheaper (improve cost), but that can happen only if I reduce access in some way or reduce quality. I can improve quality, but that will either result in increased costs or reduced access. And of course, I can increase access—as the Affordable Care Act (ACA) does—but that will either cost a lot of money (it does) or result in reduced quality.
Anyone who tells you that he or she can make the health care system more universal, improve quality, and also reduce costs is in denial or misleading you.
We can make the system cheaper. We can make it more expansive. We can make it higher in quality. But we can’t do all 3.
http://newsatjama.jama.com/2012/10/03/jama-forum-the-iron-triangle-of-he…

We have heard for decades the meme that health care access, cost and quality are interdependent. Any change in one or two of them must produce a reciprocal change in either one or both of the others. Any improvement must always be offset with one or two impairments. Yet the single payer model shows that this is merely a replication of a seriously deficient concept that omits consideration of many other important health policies.
Under a properly designed single payer model, access is improved by removing financial barriers to care for absolutely everyone. The comprehensive design features of single payer also significantly improve quality, simply stated, by ensuring that patients receive the care that they need while reducing or eliminating care that is detrimental. And costs are the forte of the single payer system. Single payer reduces waste, redirecting those funds to patient care, and puts into place economic mechanisms that slow the rate of increase in future health care costs. Spending can be contained while both quality and access are improved.
It is time to retire the meme that improving access, costs or quality can be done only by introducing impairments. Don’t let the policy community get away with that claim anymore. Aaron Carroll’s integrity is of such a high caliber that he certainly is not misleading us, but he clearly needs to end his denial.

New report on insurance plans heaping costs on patients

Many Insurance Plans Heap Healthcare Costs on Consumers

Plans with lower premiums burden members with potentially crushing costs

By Steve Sternberg and Chris I. Young
U.S. News & World Report, October 3, 2012

A first-ever U.S News analysis of nearly 6,000 health insurance plans marketed to individuals and families reveals that many of the consumers who enroll in these plans may confront budget-wrecking out-of-pocket costs that deplete their savings.

Each of the plans in the U.S. News database was scored and assigned a rating of one to five stars; plans available to both individuals and families were rated separately for each. A plan’s score depended on completeness of coverage in as many as two dozen benefit categories and subcategories—hospitalization, outpatient surgery, name-brand prescription drugs, and emergency room visits are just a few examples—and how much of the cost consumers have to pay.

The plans U.S. News rated, which are those sold to individuals and families who have no access to employer or public coverage, currently cover some 14 million people. That number could very well double once the major provisions of health reform’s Affordable Care Act take effect in 2014, according to the bipartisan Congressional Budget Office, because the ACA mandates that everyone must have health insurance or pay a penalty.

U.S. News spent several months working with data obtained from the Centers for Medicare and Medicaid Services (CMS), a federal agency that summarizes plan coverage and pricing on a consumer page but does not rate or rank plans against each other. The analysis posed many challenges, including constant flux in the number of plans available in the federal database. That is because of incomplete reporting and because health insurers periodically create new plans and stop enrolling applicants in established ones.

Research into purchasing behavior shows that health insurance shoppers are strongly influenced by the size of the monthly premium. It is a regular outlay, like a mortgage or rent payment, so weighing its impact on one’s monthly budget makes sense—to a point. An individual or family that opts for an easily affordable premium can be blindsided in the event of traumatic injury or major illness. A plan that may seem like a good choice because it has a lower monthly premium may require consumers to pay much more out-of-pocket every time they need medical care.

Plans are often far from transparent about how much consumers must pay for medical services. The term “out-of-pocket maximum,” supposedly meaning the most a consumer will have to pay for medical services, is misleading; 90 percent of plans exclude some combination of deductible, copays (upfront fees paid for service), and coinsurance (the consumer’s share of the charges). Nearly 100 plans exclude all three. A plan member with average coverage who needs surgery could end up paying thousands more than their out-of-pocket cap.

If a hospital’s physicians aren’t members of a health plan’s network, the cost may climb even higher, an expense that often comes as a shock to plan members who assume their care is covered. The same is often true for hospital services, such as occupational therapy, that are not provided by physicians.

The higher you have to climb the deductible ladder before benefits are paid out, the more vulnerable your income and savings. Medical bills tend to come in waves. A routine doctor’s visit that starts with an annual physical and progresses to a tentative diagnosis can trigger a cascade of expenses, from lab tests to prescription drugs to inpatient or outpatient hospital procedures. Plans rarely cover more than a portion of those costs, which may add up to tens of thousands of dollars when severe illness strikes.

http://health.usnews.com/health-news/health-insurance/articles/2012/10/03/many-insurance-plans-heap-healthcare-costs-on-consumers

Comment:

By Don McCanne, MD

No surprise. The title of this article says what we already knew: “Many Insurance Plans Heap Healthcare Costs on Consumers.” Further, individuals and families most often select plans based on how easily affordable the premium is, and those plans can easily exceed the supposed out-of-pocket maximum.

The Affordable Care Act includes some measures that will reduce some of the abuses of these plans, but it still leaves in place the fundamental infrastructure of private health plans. Shoppers in the state health insurance exchanges should understand that the plans they purchase will ensure neither financial security nor health security. We can do far better, beginning with establishing a single payer infrastructure.

Deaths from Uninsurance

'We're not done with health care reform yet'

By Johnathon Ross, M.D.
CommonDreams.org, Oct. 3, 2012

A recently released Census Bureau report reveals that 48.6 million Americans lack health insurance.

We know that being uninsured is dangerous to your physical and fiscal health. Research has shown that for every million uninsured, 1,000 preventable deaths occur due to untreated or undiagnosed illness.

This means 48,000 Americans will die needless deaths this year. To put this in perspective, that’s about the same number of U.S. combat deaths in Vietnam War over a decade.

President Obama and the Democrats fought to get the Affordable Care Act (ACA) passed. This was a remarkable political achievement. For 100 years, American presidents have tried to achieve health system reform. The last significant achievement was the passage of Medicare in 1965. Since then political deadlock has allowed only minor tinkering.

Sadly, the ACA is not remarkable as a policy success. Reform should have been modeled on our successful Medicare program. Instead, the ACA was modeled on the reforms passed by Mitt Romney in Massachusetts.

Massachusetts did expand coverage, as will the ACA, but the Bay State’s reforms, which rely on subsidies for the mandatory purchase of private insurance, have left 200,000 people uninsured to this day, six years later. Costs in Massachusetts have soared and continue to be the highest per capita in the world.

Fully implemented, the ACA will still leave 30 million uninsured in 2022, according to the Congressional Budget Office. That figure may climb even higher if more states decide to turn down federal Medicaid dollars, which several governors have said they may do.

But assuming all goes ahead as planned, 10 years from now we will still see about 30,000 of our friends, neighbors and family members die avoidable deaths from lack of coverage.

Keep in mind these sobering statistics do not account for the terrible suffering and disability that results when treatable illness is allowed to progress untreated, even if it does not result in death. This suffering is unmeasured.

During the debate over the ACA, a different type of reform – an improved and expanded Medicare for all – was shut out of the discussion despite popular support for this approach and despite multiple federal and state-based studies showing that the administrative cost savings from such a program would save about $400 billion yearly. Those savings would be enough to cover all the uninsured, improve benefits for all, and eliminate most out-of-pocket health spending for everyone.

As with the ACA, an improved Medicare for all would have no pre-existing condition exclusions and no lifetime limits for those with chronic conditions. Unlike the ACA, you could go to the doctor or hospital of your choice.

Under our current arrangements, dominated as they are by private health insurance companies and giant, for-profit pharmaceutical companies, we know that medical bills are responsible for over half of personal bankruptcies.

This financial suffering is passed along to all of us as bad debt and these costs are a drag on the economy. The ACA may reduce these bankruptcies somewhat, although in Massachusetts, the model for the ACA, the rate of medical bankruptcies hasn’t changed much at all.

By contrast, under an improved Medicare for all, medical bankruptcies would be a thing of the past. Patients would benefit by having ready access to comprehensive, high-quality care with no more co-pays and deductibles.

Businesses would benefit by being relieved of all the administrative burdens of our dysfunctional insurance system, a source of high costs and endless headaches. Physicians would benefit by being free of insurance company meddling and would be able to return to what they know best – caring for patients.

An improved and expanded Medicare for all will save money that can relieve the deficit. It will be good for business and the economy. It will save lives and relieve suffering.

As far as health reform goes, we are not done yet.

Johnathon Ross, M.D., M.P.H., is past president of Physicians for a National Health Program and an executive committee member of the Single Payer Action Network in Ohio.

http://www.commondreams.org/view/2012/10/03-6