PNHP

The health care 'repeal and replace' hoax

The health care 'repeal and replace' hoax

By Jack Bernard
The Charleston Gazette, July 26, 2012

CHARLESTON, W.Va. — “Repeal and replace!” That is a very catchy slogan indeed. Of course, any objective observer knows that it has very little chance of happening, but it still makes for a great sound bite.

Since 2007, the Democrats have had to override Republican Senatorial filibusters 360 times, far more than ever before. This concerns me for two reasons. First, using the filibuster thwarts democracy and may be unconstitutional. Second, excessively employing the filibuster sets a precedent for others to follow when they are in the minority.

Let’s assume a very unlikely Republican sweep occurs in 2012. Romney wins, the House stays Republican and the Senate goes for the GOP with 51 or 52 Senators. Chances are still slim that repeal will take place due to the filibuster rule. Eight or nine Democrats would have to jump ship and vote with the Republicans, my party, to repeal the law before it really has a chance to be fully implemented in 2014.

Will Rogers once stated: “I do not belong to any organized political party, I am a Democrat.” But, to a growing degree, that party is showing more solidarity in support of its positions. Why? Because moderates in both parties have been run out of office. Getting liberal Democrats to support a Republican repeal effort is highly improbable unless a compelling case can be made that what replaces it will meet with clear public support.

What should most concern my party’s leaders about its proposals is that they are unlikely to ever generate much backing from the voters. People may not approve of the insurance mandate, but that does not mean that they want the Ryan alternative: Medicare turned into a voucher program, with the risk shifted from the federal government to senior citizens. Or, that states and their taxpayers are going to happily accept the Medicaid program being turned into a block grant whereby in the long-term they have to cut services or enrollment unless they raise state taxes.

On the policy wonk side, these efforts are laughable. No systemic changes are entailed. These proposals merely shift the burden from the federal government to the elderly and the states. They do little to constrain cost increases through changes in the delivery and financing of care, unless you count forcing poorer, sicker old people to refrain from getting needed care due to the expense being dumped in their laps.

No, our current proposals fall flat politically and technically. But, do not despair, fellow Republicans. There is a solution that will get enough votes to repeal and replace: Medicare for All, with built-in cost controls. That is a way out, say my GOP friends. Not so.

Obama stole a well-established Republican idea from the 1990s to come up with Obamacare (the Affordable Care Act), which is really just Romneycare recycled. We can do the same to the Democrats by adopting their program, Universal Medicare.

Forget promoting the “free market, more competition” model. It clearly does not work in health care for a variety of reasons, including lack of comparative data and the way health care decisions are made by third parties, including the very concept of insurance.

A study recently looked at our health system versus other developed nations. One key finding is that our prices are out of control, causing our per capita costs to be far greater than elsewhere. The best way to control prices is a single-payer system, like they have in Canada and much of Europe.

Financing Universal Medicare is more straightforward than under the ACA. It can be done through payroll taxes, as Medicare and Social Security are now, with the burden split between workers and employers. There would be no insurance premiums, so the additional expense would be minimal. Plus, Medicare administrative costs are 3 percent, rather than 30 percent for the private insurers. More on Medicare for All can be found at the web site of the highly respected advocacy group Physicians for A National Healthcare Program, pnhp.org.

The Republican path to majority party status is clear. We just have to think out of the box and act decisively.

Bernard is a retired senior executive, formerly with for-profit health-care firms, who has worked on planning and cost containment issues with several hospitals in West Virginia. He is currently a small business mentor and a Republican County Commissioner in Jasper County, Ga.

http://wvgazette.com/Opinion/OpEdCommentaries/201207250065

The health care ‘repeal and replace’ hoax

By Jack Bernard
The Charleston Gazette, July 26, 2012

CHARLESTON, W.Va. — “Repeal and replace!” That is a very catchy slogan indeed. Of course, any objective observer knows that it has very little chance of happening, but it still makes for a great sound bite.

Since 2007, the Democrats have had to override Republican Senatorial filibusters 360 times, far more than ever before. This concerns me for two reasons. First, using the filibuster thwarts democracy and may be unconstitutional. Second, excessively employing the filibuster sets a precedent for others to follow when they are in the minority.

Let’s assume a very unlikely Republican sweep occurs in 2012. Romney wins, the House stays Republican and the Senate goes for the GOP with 51 or 52 Senators. Chances are still slim that repeal will take place due to the filibuster rule. Eight or nine Democrats would have to jump ship and vote with the Republicans, my party, to repeal the law before it really has a chance to be fully implemented in 2014.

Will Rogers once stated: “I do not belong to any organized political party, I am a Democrat.” But, to a growing degree, that party is showing more solidarity in support of its positions. Why? Because moderates in both parties have been run out of office. Getting liberal Democrats to support a Republican repeal effort is highly improbable unless a compelling case can be made that what replaces it will meet with clear public support.

What should most concern my party’s leaders about its proposals is that they are unlikely to ever generate much backing from the voters. People may not approve of the insurance mandate, but that does not mean that they want the Ryan alternative: Medicare turned into a voucher program, with the risk shifted from the federal government to senior citizens. Or, that states and their taxpayers are going to happily accept the Medicaid program being turned into a block grant whereby in the long-term they have to cut services or enrollment unless they raise state taxes.

On the policy wonk side, these efforts are laughable. No systemic changes are entailed. These proposals merely shift the burden from the federal government to the elderly and the states. They do little to constrain cost increases through changes in the delivery and financing of care, unless you count forcing poorer, sicker old people to refrain from getting needed care due to the expense being dumped in their laps.

No, our current proposals fall flat politically and technically. But, do not despair, fellow Republicans. There is a solution that will get enough votes to repeal and replace: Medicare for All, with built-in cost controls. That is a way out, say my GOP friends. Not so.

Obama stole a well-established Republican idea from the 1990s to come up with Obamacare (the Affordable Care Act), which is really just Romneycare recycled. We can do the same to the Democrats by adopting their program, Universal Medicare.

Forget promoting the “free market, more competition” model. It clearly does not work in health care for a variety of reasons, including lack of comparative data and the way health care decisions are made by third parties, including the very concept of insurance.

A study recently looked at our health system versus other developed nations. One key finding is that our prices are out of control, causing our per capita costs to be far greater than elsewhere. The best way to control prices is a single-payer system, like they have in Canada and much of Europe.

Financing Universal Medicare is more straightforward than under the ACA. It can be done through payroll taxes, as Medicare and Social Security are now, with the burden split between workers and employers. There would be no insurance premiums, so the additional expense would be minimal. Plus, Medicare administrative costs are 3 percent, rather than 30 percent for the private insurers. More on Medicare for All can be found at the web site of the highly respected advocacy group Physicians for A National Healthcare Program, pnhp.org.

The Republican path to majority party status is clear. We just have to think out of the box and act decisively.

Bernard is a retired senior executive, formerly with for-profit health-care firms, who has worked on planning and cost containment issues with several hospitals in West Virginia. He is currently a small business mentor and a Republican County Commissioner in Jasper County, Ga.

http://wvgazette.com/Opinion/OpEdCommentaries/201207250065

Revitalizing HMOs by relabeling them ACOs

Aurora Health Care And Aetna Form Accountable Care Collaboration, Offer New Commercial Health Care Products

Aetna
July 26, 2012

Aurora Health Care has joined with Aetna to bring employers a new type of commercial health plan designed to improve employees’ health care experience and health outcomes, while controlling costs. 

The Aurora Accountable Care Network offers a price guarantee to employers built upon a health care model that improves quality, outcomes and the patient experience. This type of price guarantee is possibly the first of its kind among accountable care models. Employers will see real savings in what they spend on health care as a result of improved patient outcomes and greater efficiencies.

Mark T. Bertolini, Aetna chairman, CEO and president, said, “We are building on our strong provider relationships to establish a nationwide accountable network that offers better care at a lower cost for everyone.  Aurora Health Care has revolutionized health care in Wisconsin. Aetna’s industry-leading care management programs and consumer tools together with Aurora’s outstanding patient care model will lead to a better overall health care experience.” 

“Aetna views accountable care organizations as a model for making health care work better for everyone,” said Bill Berenson, Aetna market president. “Aurora has demonstrated it can improve outcomes through how it integrates patient care and implements best practices. Together with Aurora, Aetna will offer more affordable and more personalized health benefits to Wisconsin employers and their employees. This is the future of health care.”  

The Aurora Accountable Care Network achieves this level of health care quality and personalized service through Aurora’s integrated system of more than 1,500 physicians, 15 hospitals and 160 clinics in eastern Wisconsin and northern Illinois.

http://www.aetna.com/news/newsReleases/2012/0726-Aetna-and-Aurora-Health-Care.html

Comment:

By Don McCanne, MD

Accountable care organizations (ACOs) are supposedly a new model of health care delivery systems which are designed to reduce health care spending while improving the quality of care. Aurora Health Care is an established integrated delivery system that recently has been approved by CMS to participate in the “shared savings” program authorized by the Affordable Care Act.

Supporters of this concept have assured us that these entities are distinctly different from HMOs. But are they?

Aurora Health Care has now joined with for-profit, private insurer Aetna as part of Aetna’s plan to “establish a nationwide accountable network that offers better care at a lower cost for everyone.”

That’s exactly what we heard during the managed care revolution when the HMO explosion took place, abandoning the model of pure integrated health systems (e.g., Kaiser Permanente), and instead establishing entities, whether composed of groups or networks, dominated by private insurers.

How can this be considered a new model when it appears to be the same old, same old. They haven’t even bothered to rearrange the deck chairs.

Single payer does not equal increased wait-times

By Dr. Aaron Carroll
The Incidental Economist, July 25, 2012

I can’t count the number of times I’ve been told this week that it’s just a “fact” that single payer systems lead to increased wait times. It appears that pointing out that this is not true is “rude”. So be it.

Let’s start with some simple facts. Wait times occur when there are too many patients and too few appointment slots. That can happen when there are too few doctors or when there are too many people who want appointments. So, yes, if you have a doctor shortage, you can get increased wait times. If the system wants to keep spending low by limiting visit slots, you can get increased wait times. If you increase the number of insured people dramatically, you will get increased wait times.

Note that any of those things can occur with or without a single payer system. They can occur with an entirely private system. If you massively decrease the number of uninsured, as the ACA will attempt to do, it’s entirely possible we will get wait times. This will happen whether people become insured through private insurance in the exchanges or through government insurance (Medicaid). The type of insurance is irrelevant. If there are way more patients calling for appointments, and the number of doctors is static, wait times will likely increase.

So if wait times are your main concern, then you’re likely against reducing the number of uninsured by any means. The outcome is the same.

None of this has anything to do with single payer.

Now it’s possible that single payer systems can lead to increased wait times. In Canada, they keep spending far below what we put out. They do so partially by spacing out visits for elective procedures and such. That’s a conscious decision, and it leads to some people waiting for elective care. But that’s an outcome of their financial conservatism, not the single payer system. Other countries (think France) don’t have the same issues with elective procedures because they spend more money. Our single payer system (Medicare) has far fewer spending restraints, and does not suffer from the wait time problem.

We could convert the entire country to Medicare tomorrow, increase the number of physicians, and have no wait times at all. We could convert the entire country to private insurance in a Switzerland-like system, make no changes to the number of physicians, and see wait times go through the roof. This really is a zombie idea.

http://theincidentaleconomist.com/wordpress/single-payer-does-not-equal-increased-wait-times/

Revitalizing HMOs by relabeling them ACOs

Aurora Health Care And Aetna Form Accountable Care Collaboration, Offer New Commercial Health Care Products

Aetna
July 26, 2012
Aurora Health Care has joined with Aetna to bring employers a new type of commercial health plan designed to improve employees’ health care experience and health outcomes, while controlling costs.
The Aurora Accountable Care Network offers a price guarantee to employers built upon a health care model that improves quality, outcomes and the patient experience. This type of price guarantee is possibly the first of its kind among accountable care models. Employers will see real savings in what they spend on health care as a result of improved patient outcomes and greater efficiencies.
Mark T. Bertolini, Aetna chairman, CEO and president, said, “We are building on our strong provider relationships to establish a nationwide accountable network that offers better care at a lower cost for everyone.  Aurora Health Care has revolutionized health care in Wisconsin. Aetna’s industry-leading care management programs and consumer tools together with Aurora’s outstanding patient care model will lead to a better overall health care experience.”
“Aetna views accountable care organizations as a model for making health care work better for everyone,” said Bill Berenson, Aetna market president. “Aurora has demonstrated it can improve outcomes through how it integrates patient care and implements best practices. Together with Aurora, Aetna will offer more affordable and more personalized health benefits to Wisconsin employers and their employees. This is the future of health care.”
The Aurora Accountable Care Network achieves this level of health care quality and personalized service through Aurora’s integrated system of more than 1,500 physicians, 15 hospitals and 160 clinics in eastern Wisconsin and northern Illinois.
http://www.aetna.com/news/newsReleases/2012/0726-Aetna-and-Aurora-Health-Care.html

Accountable care organizations (ACOs) are supposedly a new model of health care delivery systems which are designed to reduce health care spending while improving the quality of care. Aurora Health Care is an established integrated delivery system that recently has been approved by CMS to participate in the “shared savings” program authorized by the Affordable Care Act.
Supporters of this concept have assured us that these entities are distinctly different from HMOs. But are they?
Aurora Health Care has now joined with for-profit, private insurer Aetna as part of Aetna’s plan to “establish a nationwide accountable network that offers better care at a lower cost for everyone.”
That’s exactly what we heard during the managed care revolution when the HMO explosion took place, abandoning the model of pure integrated health systems (e.g., Kaiser Permanente), and instead establishing entities, whether composed of groups or networks, dominated by private insurers.
How can this be considered a new model when it appears to be the same old, same old. They haven’t even bothered to rearrange the deck chairs.

Stuart Butler on the 30 million uninsured

The New ACA Score And The Perils Of Letting Cost Estimates Drive Policymaking

by Stuart Butler
Health Affairs Blog, July 24, 2012

If you were expecting the Congressional Budget Office (CBO) recalculation of the Affordable Care Act (ACA) to rival the drama of the Supreme Court decision, you will have been disappointed.  But the new CBO re-estimate underscores the dangers of basing major policy changes on such forecasts.

While the Court caused political shockwaves by declaring the ACA’s “penalty” to be a “tax”, that in itself did not have major implications for the new score.  CBO projects a net reduction in total federal outlays of $84 billion over 10 years (the new total is $1,168 billion) and an increase in the uninsured of about 3 million, when compared with its earlier estimates.  Significant numbers, but not earth-shattering.  The Joint Committee on Taxation provided revenue estimates for the CBO forecast.

But CBO faced enormous challenges in estimating the impact of the ruling, and its seemingly precise estimate clouds the significant guesses it had to make.

The Challenge Facing CBO

Rather than the tax-not-penalty decision, the part of the Court’s ruling with the greatest budgetary implications concerned Medicaid.  It also gave CBO its biggest headache.  The Court struck down the provision requiring states to expand Medicaid coverage to households up to 133 percent of the poverty level.  So CBO had to figure how many states – indeed which states, given different Medicaid coverage pattern today in the states – would decline short-term federal funding for the expansion (what the Wall Street Journal called the “teaser rate”), knowing they would have to pay a portion of the cost in future years.  The governors of several states, including Texas, Florida and South Carolina, have already declared they would refuse the money.

So what could CBO do?  Take such declarations at face value?  Factor in a bit of politics, consult a political crystal ball, and predict what might actually happen in state houses next year? Give a range to show, say, the different effects of all states declining or all agreeing to expand Medicaid?

To compound the scoring challenge, CBO had to project what would happen to newly eligible Medicaid households in states that decline federal money to expand Medicaid.  Some, but not all, would be eligible for subsidies in the new ACA exchanges, depending on household income.  But how many would sign up (adding to subsidy costs, even though they would not have added to federal Medicaid costs)?

According to former CBO Director Douglas Holtz-Eakin, depending on your guess the potential range of budgetary effects would be large.  If the six states currently saying they will not expand Medicaid follow through with that threat, Holz-Eakin estimates the net budget impact would be $22-80 billion between 2014 (when the expansion occurs) and 2021.  But if all states decide the expansion is an offer they must refuse because of the long-term state cost, the impact could be as high $627 billion.

A False Sense Of Certainty

Faced with the uncertainty about state action, CBO declined to give a range (a bad thing).  Instead it avoided second-guessing states (arguably a good thing for people who wear green eyeshades rather than appear on political talk shows) and projected a number based on “the middle of the distribution of possible outcomes.” That’s defensible, in the same sense as a weather forecaster splitting the difference on the chances of thunderstorms next Friday, but it results in a seemingly precise number that is almost certainly wrong and yet gives a false sense of certainty to policymakers.

This case of CBO scoring highlights once again why it is so important for policy to be driven a bit less by budget estimators generating apparently precise numbers.  That leads to policies based on guesses needed for a computer algorithm rather than on judgment and public discourse about the nature and purpose of government.  But alas, Congress insists that CBO come up with one number for its deliberations, not a range or a zone of probability.  And so even though CBO wisely warns that its number “should not be viewed as representing a single definitive interpretation of how the ACA should or will be implemented in light of the Court’s decision,” regrettably it will be.

Posted response by Don McCanne:

The policies inherent in the Affordable Care Act do create uncertainty as to how many will remain uninsured. Nevertheless, the CBO projection of 30 million uninsured will be the number quoted in policy discussions, since it is the best we have, and it does provide a rough estimate of how short ACA falls in the goal of covering everyone.

To provide a perspective of the enormity of this policy failure, let’s assume that we chose a different set of policies that would cover the same total number of individuals, still leaving 30 million uninsured. Let’s say that we want to have 100 percent coverage in each state, beginning with the largest states since they would have the greatest health care burden in terms of the sheer numbers of patients. Let’s continue to cover 100 percent of each state until we run out of funds to pay for coverage for the last 30 million people – the residents of the least populated states.

Under such a policy, everyone would be covered except all of the residents of Alaska, Arkansas, Delaware, District of Columbia, Hawaii, Idaho, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming.

Who could ever support such a ridiculous policy scheme? Yet since we have buried other ridiculous policies into a highly dysfunctional, fragmented, administratively wasteful ACA financing scheme, we are going to accept those policies as the best we can do? It’s okay to have 30 million uninsured as long as we don’t concentrate them in two-fifths of our states?

Stuart Butler implies that we need policies based on “judgment and public discourse about the nature and purpose of government.” If we were all sincere in such a discourse, and laid partisanship aside, we would end up with a decision to enact a single payer national health program that included everyone.

http://healthaffairs.org/blog/2012/07/24/the-new-aca-score-and-the-perils-of-letting-cost-estimates-drive-policymaking/

Comment:

By Don McCanne, MD

Stuart Butler has a valid point that the variables in the Affordable Care Act and its implementation are great enough that we cannot accurately predict the precise numbers of individuals who will remain uninsured. The information that the Congressional Budget Office relied on to come up with 30 million uninsured does give us a very rough estimate of the total, and enough confidence that we can say with certainty that at least tens of millions will remain uninsured.

So what is Stuart Butler’s point? He indicates that instead of using this precise number to establish policy, we should choose policies based on “judgment and public discourse about the nature and purpose of government.” Well, let’s use the less precise estimate of tens of millions uninsured. What then should be the role of government?

It is clear that the private sector has been incapable of insuring everyone, and that government involvement is required if universal coverage and access are to be our goals. It is also clear that the Affordable Care Act is not an adequate response on the part of government since that is what led to this e
stimate of the large numbers who will remain uninsured.

So what would Butler propose? In 1989, we thought we knew the answer when he coauthored the report from the Heritage Foundation which called for the principle that, “Every resident of the U.S. must, by law, be enrolled in an adequate health care plan to cover major health care costs,” and “The requirement to obtain basic insurance would have to be enforced,” and “If the family did not enroll… a fine might be imposed.” Yes, an individual mandate.

This did prove to be partisan since the concept was used in proposed Republican legislation designed to counter the health care reform proposal of Bill and Hillary Clinton. The Clinton effort fizzled, and the Republican proposals were never enacted. Little did we realize then that a couple decades later the partisan support for the individual mandate would flip from the Republicans to the Democrats.

In a USA TODAY op-ed this year, Butler indicated that his views had changed based on newer policy research, and that today the individual mandate “means the government makes people buy comprehensive benefits for their own good, rather than our original emphasis on protecting society from the heavy medical costs of free riders.” Sort of, you take care of your own needs but don’t turn to me for help when you can’t meet them – the perpetual conflict between individual responsibility and social solidarity.

He wrote, “health research and advances in economic analysis have convinced people like me that an insurance mandate isn’t needed to achieve stable, near-universal coverage. For example, the new field of behavioral economics taught me that default auto-enrollment in employer or nonemployer insurance plans can lead many people to buy coverage without a requirement.”

We know that default auto-enrollment does result in higher rates of participation, but we also know that an entirely voluntary program for purchasing our often unaffordable private health plans would leave far more uninsured than would the policies contained in the Affordable Care Act.

We should have that public discourse that Butler calls for – the one about what we, as a nation, want. Do we want absolutely everyone to be included in our health care system? Or do we want to continue with policies that provide the equivalent of covering everyone in the most populous states, but none of the residents of Alaska, Arkansas, Delaware, District of Columbia, Hawaii, Idaho, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming?

Heritage Foundation: “A National Health System for America” 1/2/89
http://www.heritage.org/research/reports/1989/a-national-health-system-for-america

USA TODAY: “Don’t blame Heritage for ObamaCare mandate” by Stuart Butler
http://www.usatoday.com/news/opinion/forum/story/2012-02-03/health-individual-mandate-reform-heritage/52951140/1

Better than this

By Dave Dvorak, M.D.
Minnesota Medicine, July 25, 2012

“How much will this cost?” he asks. It’s the question at the heart of any business transaction: Is this new car, this plane ticket, this iPad worth the asking price?

But the man sitting before me is not a customer in an automobile showroom or an electronics store. He is my patient in the emergency department, and he is weighing whether to undergo the chest CT scan I have just recommended.

“I’m uninsured,” he says. “I lost my health coverage when I got laid off from my job three years ago. This is all coming out of my pocket.”

An ex-smoker in his late 40s, he has been coughing up increasing amounts of bloody sputum over the past month. What began as occasional, tiny red flecks has progressed to thick crimson streaks he can no longer ignore.

“I can only give you an estimate,” I say, “but I’m guessing a chest CT scan plus the radiologist’s fee will run in the neighborhood of $2,000.”

Like most emergency physicians, I have catalogued in my brain an endless litany of precise numbers—physiologic parameters, normal lab values, weight-based drug doses. But when it comes to knowing the costs of the myriad tests, medications and treatments that I routinely order for patients, I can offer little more than a rough estimate.

“I was afraid you’d say something like that,” he says. “I figured CT scans don’t come cheap.” He sighs quietly. “I’m raising my 8-year-old daughter on a pretty lean budget.” He looks thin in his hospital gown and a shade pale, a few days of graying stubble on his chin.

“But I’ve been worried about this for too long,” he says. “I know I need to have it.”

An hour later, I am seated at my computer scrolling through digital CT images while the radiologist on the phone describes the findings.

“In the hilum of the left lung there is a 4.5 centimeter lesion very likely to represent malignancy,” she says. My gaze falls on the irregularly shaped white mass, its tiny tentacles invading the delicate latticework of the surrounding lung tissue.

“Unfortunately, it gets worse,” the radiologist says. “There are also multiple scattered smaller lesions throughout both lungs, highly suspicious for metastases.”

There was a time during medical school and residency when I regarded abnormal clinical and radiographic findings with intrigue. I remember the excitement of hearing my first heart murmur. Of palpating a thyroid nodule. Of visualizing an ovarian mass on pelvic ultrasound.

But after years of clinical practice and countless patient encounters, I now find it difficult to view abnormal findings separately from the human lives they affect. I see an elderly woman’s hip X-ray, knowing that the fracture line coursing through the femoral neck likely spells the end of her days of independent living. A peculiar bright patch lighting up in the brain’s left hemisphere on an MRI scan signifies that a man will no longer be able to grasp a pen or a coffee mug in his right hand, will never again be able to speak a meaningful word to his family.

I hang up the phone, my eyes lingering on the CT images, the sinister white lung mass and its small-but-ominous satellites. And I am aware of their significance—that a middle-aged man will not live to see his daughter’s wedding.

I return to the patient’s room and sit down on the bedside stool. Before I speak, I feel his gaze upon me, anxiously searching my face for any subtle indication of the words to come.

“I’m sorry to have to give you this news,” I say, “but your CT scan shows findings concerning for lung cancer. It’s possibly spread to both lungs.”

He stares ahead, unblinking, his facial pallor seemingly more apparent. After a few moments, he speaks.

“On some level, I was expecting something really bad like this,” he says. “But, of course, you always hope that everything will turn out fine.”

My mouth, having grown dry, lacks the appropriate words to console him in this moment of utter sorrow. So I put a hand on his arm.

“I’ll talk to our on-call oncologist,” I tell him. “We’ll figure out a plan for you.”

He waits patiently until I return to his room once more, armed with an action plan.

“The oncologist is going to admit you to the hospital and start the workup,” I explain. “He’ll order a PET scan to see if there’s been spread to other parts of the body. Then they’ll do a biopsy of that main lesion in your lung to determine the best treatment options—whether it be radiation, chemotherapy or some combination of the two.”

A long period of silence follows, time for my patient to process the information I have conveyed. I anticipate forthcoming questions.

“I suspected that you’d want to do all those things,” he says, finally. “But I’ve already been thinking this through, and I’ve decided that I’m going to have to pass on your recommendations.”

It is not a reply I was expecting. “Why is that?” I ask.

“As I said before, I’ve got no health insurance,” he says. “But there’s one thing I do have—my house. And it’s fully paid for. I guess I’m not willing to mortgage it—and ultimately lose it—to pay off endless medical bills. My house is the only thing…” His voice trails off.

After a pause, he continues. “My house is the only thing I’ll have to leave my daughter when I’m gone.”

Tears have gathered in the corners of his eyes. I offer him a box of tissues, and he takes one.

We sit together in a room in a modern emergency department in a rich country, a land where highly trained specialists confidently wield the newest technologies and expensive pharmaceuticals. But these treasures are not accessible to all, for ours is also a land where private health insurance is bought and sold as a commodity. Ours is a system known to shake down sick people for money they don’t have. Ours is the only wealthy democracy that fails to guarantee health coverage to all of its citizens.

Just as it is failing now.

He looks down at his watch. “Thanks for all you’ve done. I really appreciate it. But I’ve gotta leave now,” he says. “I have to go pick her up from school.”

As I watch him reach behind his neck to untie his hospital gown, I can’t help but feel that we owe him so much more. I can’t help but feel that we—health care providers, hospital administrators, insurance company executives, politicians, all those who strenuously fight the changes that our system desperately needs—we all have failed him.

I can’t help but feel that we are better than this.

PNHP note: Dave Dvorak, M.D., M.P.H., practices emergency medicine in Edina, Minn. This article led to his being declared “physician winner” in Minnesota Medicine’s ninth annual writing contest. Dvorak is a member of Minnesota Physicians for a National Health Program.

2012, Minnesota Medical Association

http://www.minnesotamedicine.com/CurrentIssue/Betterthanthis.aspx

Stuart Butler on the 30 million uninsured

The New ACA Score And The Perils Of Letting Cost Estimates Drive Policymaking

by Stuart Butler
Health Affairs Blog, July 24, 2012
If you were expecting the Congressional Budget Office (CBO) recalculation of the Affordable Care Act (ACA) to rival the drama of the Supreme Court decision, you will have been disappointed.  But the new CBO re-estimate underscores the dangers of basing major policy changes on such forecasts.
While the Court caused political shockwaves by declaring the ACA’s “penalty” to be a “tax”, that in itself did not have major implications for the new score.  CBO projects a net reduction in total federal outlays of $84 billion over 10 years (the new total is $1,168 billion) and an increase in the uninsured of about 3 million, when compared with its earlier estimates.  Significant numbers, but not earth-shattering.  The Joint Committee on Taxation provided revenue estimates for the CBO forecast.
But CBO faced enormous challenges in estimating the impact of the ruling, and its seemingly precise estimate clouds the significant guesses it had to make.
The Challenge Facing CBO
Rather than the tax-not-penalty decision, the part of the Court’s ruling with the greatest budgetary implications concerned Medicaid.  It also gave CBO its biggest headache.  The Court struck down the provision requiring states to expand Medicaid coverage to households up to 133 percent of the poverty level.  So CBO had to figure how many states – indeed which states, given different Medicaid coverage pattern today in the states – would decline short-term federal funding for the expansion (what the Wall Street Journal called the “teaser rate”), knowing they would have to pay a portion of the cost in future years.  The governors of several states, including Texas, Florida and South Carolina, have already declared they would refuse the money.
So what could CBO do?  Take such declarations at face value?  Factor in a bit of politics, consult a political crystal ball, and predict what might actually happen in state houses next year? Give a range to show, say, the different effects of all states declining or all agreeing to expand Medicaid?
To compound the scoring challenge, CBO had to project what would happen to newly eligible Medicaid households in states that decline federal money to expand Medicaid.  Some, but not all, would be eligible for subsidies in the new ACA exchanges, depending on household income.  But how many would sign up (adding to subsidy costs, even though they would not have added to federal Medicaid costs)?
According to former CBO Director Douglas Holtz-Eakin, depending on your guess the potential range of budgetary effects would be large.  If the six states currently saying they will not expand Medicaid follow through with that threat, Holz-Eakin estimates the net budget impact would be $22-80 billion between 2014 (when the expansion occurs) and 2021.  But if all states decide the expansion is an offer they must refuse because of the long-term state cost, the impact could be as high $627 billion.
A False Sense Of Certainty
Faced with the uncertainty about state action, CBO declined to give a range (a bad thing).  Instead it avoided second-guessing states (arguably a good thing for people who wear green eyeshades rather than appear on political talk shows) and projected a number based on “the middle of the distribution of possible outcomes.” That’s defensible, in the same sense as a weather forecaster splitting the difference on the chances of thunderstorms next Friday, but it results in a seemingly precise number that is almost certainly wrong and yet gives a false sense of certainty to policymakers.
This case of CBO scoring highlights once again why it is so important for policy to be driven a bit less by budget estimators generating apparently precise numbers.  That leads to policies based on guesses needed for a computer algorithm rather than on judgment and public discourse about the nature and purpose of government.  But alas, Congress insists that CBO come up with one number for its deliberations, not a range or a zone of probability.  And so even though CBO wisely warns that its number “should not be viewed as representing a single definitive interpretation of how the ACA should or will be implemented in light of the Court’s decision,” regrettably it will be.
Posted response by Don McCanne:
The policies inherent in the Affordable Care Act do create uncertainty as to how many will remain uninsured. Nevertheless, the CBO projection of 30 million uninsured will be the number quoted in policy discussions, since it is the best we have, and it does provide a rough estimate of how short ACA falls in the goal of covering everyone.
To provide a perspective of the enormity of this policy failure, let’s assume that we chose a different set of policies that would cover the same total number of individuals, still leaving 30 million uninsured. Let’s say that we want to have 100 percent coverage in each state, beginning with the largest states since they would have the greatest health care burden in terms of the sheer numbers of patients. Let’s continue to cover 100 percent of each state until we run out of funds to pay for coverage for the last 30 million people – the residents of the least populated states.
Under such a policy, everyone would be covered except all of the residents of Alaska, Arkansas, Delaware, District of Columbia, Hawaii, Idaho, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming.
Who could ever support such a ridiculous policy scheme? Yet since we have buried other ridiculous policies into a highly dysfunctional, fragmented, administratively wasteful ACA financing scheme, we are going to accept those policies as the best we can do? It’s okay to have 30 million uninsured as long as we don’t concentrate them in two-fifths of our states?
Stuart Butler implies that we need policies based on “judgment and public discourse about the nature and purpose of government.” If we were all sincere in such a discourse, and laid partisanship aside, we would end up with a decision to enact a single payer national health program that included everyone.
http://healthaffairs.org/blog/2012/07/24/the-new-aca-score-and-the-perils-of-letting-cost-estimates-drive-policymaking/

Stuart Butler has a valid point that the variables in the Affordable Care Act and its implementation are great enough that we cannot accurately predict the precise numbers of individuals who will remain uninsured. The information that the Congressional Budget Office relied on to come up with 30 million uninsured does give us a very rough estimate of the total, and enough confidence that we can say with certainty that at least tens of millions will remain uninsured.
So what is Stuart Butler’s point? He indicates that instead of using this precise number to establish policy, we should choose policies based on “judgment and public discourse about the nature and purpose of government.” Well, let’s use the less precise estimate of tens of millions uninsured. What then should be the role of government?
It is clear that the private sector has been incapable of insuring everyone, and that government involvement is required if universal coverage and access are to be our goals. It is also clear that the Affordable Care Act is not an adequate response on the part of government since that is what led to this estimate of the large numbers who will remain uninsured.
So what would Butler propose? In 1989, we thought we knew the answer when he coauthored the report from the Heritage Foundation which called for the principle that, “Every resident of the U.S. must, by law, be enrolled in an adequate health care plan to cover major health care costs,” and “The requirement to obtain basic insurance would have to be enforced,” and “If the family did not enroll… a fine might be imposed.” Yes, an individual mandate.
This did prove to be partisan since the concept was used in proposed Republican legislation designed to counter the health care reform proposal of Bill and Hillary Clinton. The Clinton effort fizzled, and the Republican proposals were never enacted. Little did we realize then that a couple decades later the partisan support for the individual mandate would flip from the Republicans to the Democrats.
In a USA TODAY op-ed this year, Butler indicated that his views had changed based on newer policy research, and that today the individual mandate “means the government makes people buy comprehensive benefits for their own good, rather than our original emphasis on protecting society from the heavy medical costs of free riders.” Sort of, you take care of your own needs but don’t turn to me for help when you can’t meet them – the perpetual conflict between individual responsibility and social solidarity.
He wrote, “health research and advances in economic analysis have convinced people like me that an insurance mandate isn’t needed to achieve stable, near-universal coverage. For example, the new field of behavioral economics taught me that default auto-enrollment in employer or nonemployer insurance plans can lead many people to buy coverage without a requirement.”
We know that default auto-enrollment does result in higher rates of participation, but we also know that an entirely voluntary program for purchasing our often unaffordable private health plans would leave far more uninsured than would the policies contained in the Affordable Care Act.
We should have that public discourse that Butler calls for – the one about what we, as a nation, want. Do we want absolutely everyone to be included in our health care system? Or do we want to continue with policies that provide the equivalent of covering everyone in the most populous states, but none of the residents of Alaska, Arkansas, Delaware, District of Columbia, Hawaii, Idaho, Kansas, Maine, Mississippi, Montana, Nebraska, Nevada, New Hampshire, New Mexico, North Dakota, Rhode Island, South Dakota, Vermont, West Virginia, and Wyoming?
Heritage Foundation: “A National Health System for America” 1/2/89
http://www.heritage.org/research/reports/1989/a-national-health-system-for-america
USA TODAY: “Don’t blame Heritage for ObamaCare mandate” by Stuart Butler
http://www.usatoday.com/news/opinion/forum/story/2012-02-03/health-individual-mandate-reform-heritage/52951140/1

How I Lost My Fear of Universal Health Care

RH Reality Check, July 16, 2012

The following article was written by Melissa @PermissionToLive, who has chosen to use her first name only.

When I moved to Canada in 2008, I was a die-hard conservative Republican. So when I found out that we were going to be covered by Canada’s Universal Health Care, I was somewhat disgusted. This meant we couldn’t choose our own health coverage, or even opt out if we wanted too. It also meant that abortion was covered by our taxes, something I had always believed was horrible. I believed based on my politics that government mandated health care was a violation of my freedom.

When I got pregnant shortly after moving, I was apprehensive. Would I even be able to have a home birth like I had experienced with my first 2 babies? Universal Health Care meant less choice right? So I would be forced to do whatever the medical system dictated regardless of my feelings, because of the government mandate. I even talked some of having my baby across the border in the US, where I could pay out of pocket for whatever birth I wanted. So imagine my surprise when I discovered that midwives were not only covered by the Universal health care, they were encouraged! Even for hospital births. In Canada, midwives and doctors were both respected, and often worked together. 

I went to my first midwife appointment and sat in the waiting room looking at the wall of informational pamphlets. I never went to the doctor growing up, we didn’t have health insurance, and my parents preferred a conservative naturopathic doctor anyways. And the doctor I had used for my first 2 births was also a conservative Christian. So I had never seen information on birth control and STDs. One of the pamphlets read “Pregnant Unexpectedly?” so I picked it up, wondering what it would say. The pamphlet talked about adoption, parenthood, or abortion. It went through the basics of what each option would entail and ended by saying that these choices were up to you. I was horrified that they included abortion on the list of options, and the fact that the pamphlet was so balanced instead of “pro-life.” 

During my appointment that day, the midwife asked her initial round of questions including whether or not I had desired to become pregnant in the first place. Looking back I am not surprised she asked that, I was depressed at the time, (even though I did not list that on my medical chart) and very vocal about my views on birth control (it wasn’t OK, ever.) No wonder she felt like she should ask if I was happy to be having this baby. But I was angry about the whole thing. In my mind, freedom was being violated, my rights were being decided for me by the evils of Universal Health Care.

Fast forward a little past the Canadian births of my third and fourth babies. I had better prenatal care than I had ever had in the States. I came in regularly for appointments to check on my health and my babies’ health throughout my pregnancy, and I never had to worry about how much a test cost or how much the blood draw fee was. With my pregnancies in the States, I had limited my checkups to only a handful to keep costs down. When I went in to get the shot I needed because of my negative blood type, it was covered. In fact I got the recommended 2 doses instead of the more risky 1 dose because I didn’t have to worry about the expense. I had a wide array of options and flexibility when it came to my birth, and care providers that were more concerned with my health and the health of my baby than how much money they might make based on my birth, or what might impact their reputation best. When health care is universal, Drs are free to recommend and provide the best care for every patient instead of basing their care on what each patient can afford.

I found out that religious rights were still respected. The Catholic hospital in the area did not provide abortions, and they were not required too. I had an amazing medically safe birth, and excellent post-natal care with midwives who had to be trained, certified and approved by the medical system.

I started to feel differently about Universal government mandated and regulated Health care. I realized how many times my family had avoided hospital care because of our lack of coverage. When I mentioned to Canadians that I had been in a car accident as a teen and hadn’t gone into the hospital, they were shocked! Here, you always went to the hospital, just in case. And the back issue I had since the accident would have been helped by prescribed chiropractic care which would have been at no cost to me. When I asked for prayers for my little brother who had been burned in a camping accident, they were all puzzled why the story did not include immediately rushing him to the hospital. When they asked me to clarify and I explained that many people in the States are not insured and they try to put off medical care unless absolutely needed, they literally could not comprehend such a thing.

I started to wonder why I had been so opposed to government mandated Universal Health care. Here in Canada, everyone was covered. If they worked full-time, if they worked part-time, or if they were homeless and lived on the street, they were all entitled to the same level of care if they had a medical need. People actually went in for routine check-ups and caught many of their illnesses early, before they were too advanced to treat. People were free to quit a job they hated, or even start their own business without fear of losing their medical coverage. In fact, the only real complaint I heard about the universal health care from the Canadians themselves, was that sometimes there could be a wait time before a particular medical service could be provided. But even that didn’t seem to be that bad to me, in the States most people had to wait for medical care, or even be denied based on their coverage. The only people guaranteed immediate and full service in the USA, were those with the best (and most expensive) health coverage or wads of cash they could blow. In Canada, the wait times were usually short, and applied to everyone regardless of wealth. If you were discontent with the wait time (and had the money to cover it) you could always travel out of the country to someplace where you could demand a particular service for a price. Personally, I never experienced excessive wait times, I was accepted for maternity care within a few days or weeks, I was able to find a family care provider nearby easily and quickly, and when a child needed to be brought in for a health concern I was always able to get an appointment within that week.

The only concern I was left with was the fact that abortion was covered by the universal health care, and I still believed that was wrong. But as I lived there, I began to discover I had been misled in that understanding as well. Abortion wasn’t pushed as the only option by virtue of it being covered. It was just one of the options, same as it was in the USA. In fact, the percentage rates of abortion are far lower in Canada than they are in the USA, where abortion is not covered by insurance and is often much harder to get. In 2008 Canada had an abortion rate of 15.2 per 1000 women (In other countries with government health care that number is even lower), and the USA had an abortion rate of 20.8 abortions per 1000 women. And suddenly I could see why that was the case. With Universal coverage, a mother pregnant unexpectedly would still have health care for her pregnancy and birth even if she was unemployed, had to quit her job, or lost her job. 

If she was informed that she had a special needs baby on the way, she could rest assured knowing in Canada her child’s health care needs would be covered. Whether your child needs therapy, medicines, a caregiver, a wheelchair, or repeated surgeries, it would be covered by the
health care system. Here, you never heard of parents joining the army just so their child’s “pre-existing” health care needs would be covered. In fact, when a special needs person becomes an adult in Canada, they are eligible for a personal care assistant covered by the government. We saw far more developmentally or physically disabled persons out and about in Canada, than I ever see here in the USA. They would be getting their groceries at the store, doing their business at the bank, and even working job, all with their personal care assistant alongside them, encouraging them and helping them when they needed it. When my sister came up to visit, she even commented on how visible special needs people were when the lady smiling and waving while clearing tables at the Taco Bell with her caregiver clearly had Downs Syndrome. 

I also discovered that the Canadian government looked out for it’s families in other ways. The country mandates one year of paid maternity leave, meaning a woman having a baby gets an entire year after the birth of her baby to recover and parent her new baby full-time, while still receiving 55% of her salary and their job back at the end of that year. Either parent can use the leave, so some split it, with one parent staying at home for 6 months and the other staying at home for 6 months. I could hardly believe my ears when I first heard it. In America, women routinely had to return to work after 6 weeks leave, many times unpaid. Many American women lost their jobs when becoming pregnant or having a baby. I knew people who had to go back to work 2 weeks after giving birth just to hang onto their job and continue making enough money to pay the bills. Also every child in Canada gets a monthly cash tax benefit. The wealthier families can put theirs into a savings account to pay for college someday (which also costs far less money in Canada by the way), the not so wealthy can use theirs to buy that car seat or even groceries. In the province we lived in, we also received a monthly day care supplement check for every child under school age. I made more money being a stay at home mom in Canada than I do in the States working a close to a minimum wage job. And none of the things I listed here are considered “welfare” they are available to every Canadian regardless of income. For those with lower incomes than we had there are other supports in place as well.

If a woman gets pregnant unexpectedly in America, she has to worry about how she will get her own prenatal care, medical care for her child, whether or not she will be able to keep her job and how she will pay for daycare for her child so she can continue to support her family. In Canada those problems are eliminated or at least reduced. Where do you think a woman is more likely to feel supported in her decision to keep her baby, and therefore reduce abortions? 

Since all of these benefits are available to everyone, I never heard Canadians talking about capping their incomes to remain lower income and not lose their government provided health coverage. Older people in Canada don’t have to clean out their assets to qualify for some Medicare or Social Security programs, I heard of inheritances being left even amongst the middle classes. Something I had only heard about in wealthy families in the USA.

And lest you think that the Canada system is draining the government resources, their budget is  very close to balanced every year. They’ve had these programs for decades. Last year Canada’s national debt was 586 billion dollars, the USA has 15.5 trillion dollars in national debt. Canada has about one 10th the population of the US, so even accounting for size, the USA is almost 3 times more indebted. And lest you think that taxes are astronomical, our median income taxes each year were only slightly higher than they had been in the States, and we still got a large chunk of it back each year at tax time.

In the end, I don’t see Universal health care as an evil thing anymore. Comparing the two systems, which one better values the life of each person? Which system is truly more family friendly?

Former Quiverfull believer, Melissa is a member of the Spiritual Abuse Survivor Blogs Network at No Longer Quivering – she blogs at Permission to Live.

http://www.rhrealitycheck.org/article/2012/07/12/how-i-lost-my-fear-universal-health-care

More Aetna abuses, but wait, there's worse

Aetna sued over out-of-network pay and referrals

By Alicia Gallegos
American Medical News, July 23, 2012

The California Medical Assn. and more than 50 physicians are suing Aetna over alleged retaliation against doctors who refer patients for out-of-network care.

The medical society and doctors say Aetna is underpaying out-of-network physicians, refusing to authorize some out-of-network services and illegally terminating the contracts of doctors who make such referrals.

The insurer’s practices violate California law and interfere with doctors’ medical decisions, said Long X. Do, CMA legal counsel.

The plaintiffs claim some of Aetna’s insurance policies enable patients to receive out-of-network care. However, Aetna discourages such practices and regularly refuses to pay for them, the suit claims.

Similarly, doctors’ contracts with Aetna do not specifically forbid all out-of-network referrals, the suit said. Yet, when doctors make such referrals, Aetna frequently threatens them with a “rate adjustment” or termination from Aetna’s network, according to the suit.

In a statement, Aetna spokeswoman Anjanette Coplin called the suit baseless and denied the insurer is mistreating physicians.

“Doctors who entice patients to have procedures performed at out-of-network facilities that they own without the patient’s knowledge are putting profits over their patients,” she said. “The wildly inflated bills of these facilities drive up the out-of-pocket costs for unwitting patients and needlessly add to premium costs for everyone.”

The CMA is aware of Aetna’s lawsuits, but said its suit has nothing to do with them. CMA’s claim centers on Aetna’s policies and practices, Do said.

http://www.ama-assn.org/amednews/2012/07/23/prsa0723.htm

And…

Silicon Valley Surgeons Risk ‘Moral Authority’ For 200% Returns

By Peter Waldman
Bloomberg, July 18, 2012

The anesthesiolgists’ ball in December 2010 was already raging when Dr. Thomas Elardo and his wife arrived. It was 11 p.m., and the Opera House in downtown Los Gatos, California, was packed with nurses and doctors dancing to ’80s covers by The Microbes, an all-doctor band. Elardo climbed the stairs to the mezzanine bar and was immediately gladhanded by Bobby Sarnevesht, a local entrepreneur, and orthopedist Samir Sharma, who pulled Elardo aside.

Elardo had known Sharma for years, but the orthopedist had never given him the time of day. That night was different — he had something to show Elardo. At the bar, Sharma flaunted a $960,000 check, Elardo recalls. Sharma said it was for his work as a surgeon and investor in an outpatient surgery center in Los Gatos, operated by Sarnevesht.

“They were saying, ‘This is the kind of money you can make. You’ve gotta come in!” recalls Elardo. “I was speechless.”

Founded by Sarnevesht and his mother, Julia Hashemieh, Bay Area Surgical Management has marshaled decades of doctor rage against insurance carriers into a profitable business.

By rejecting the discounted contracts that participating in-network providers sign with insurers, the surgery centers bill insurance companies at their own out-of-network rates, which are 5 to 35 times as much as the in-network facilities charge, and make a killing.

Knee arthroscopies that cost $3,000 in Aetna Inc. (AET)’s network earn nearly $20,000 in facility fees at Bay Area’s surgery centers, according to Aetna, the Hartford, Connecticut-based health insurer. A bunion repair that costs $3,700 in-network got almost $53,000 for Bay Area Surgical Group, one such center. A disc surgery for lower-back pain, called a laminectomy, costs about $6,000 in network yet reaps nearly $120,000 for Bay Area Surgical.

Fed up, Aetna sued Hashemieh and partners in February, claiming they gouge on rates, pay surgeons excessive compensation for referrals and defraud health plans.

http://www.bloomberg.com/news/2012-07-19/silicon-valley-surgeons-risk-moral-authority-for-200-returns.html

Comment: 

By Don McCanne, MD

Although it is always tempting to take on the abuses of private insurers such as Aetna, this time we should look further: the system by which we finance health care in the United States.

Perhaps the most important contribution of the private insurance industry in the past several decades has been the slowing of health care price increases through the process of provider contracting. Of course, public insurers such as Medicare are more effective, though through administered pricing rather than contracting. Nevertheless, health care prices would be even higher had the private insurers not engaged in contracting.

A problem that has never been satisfactorily resolved, in spite of many efforts, is what to do about charges by physicians and facilities that do not have contracts with the insurers – out-of-network providers. In some instances, the insurers pay nothing, except when required by law in certain emergency situations. In other instances, the insurers may pay at lower rates than they do for in-network providers, leaving the high balances as the responsibility of the patients. Often insurers will attempt to negotiate rates after the fact in order to prevent their clients from being stuck with these very high balances.

It is the latter situation that has become a problem. The Bloomberg article above (a very long, ugly story) goes into detail explaining how some entrepreneurial types in the health care delivery system have leveraged out-of-network care into a very lucrative operation. I dare say that Aetna looks like a saintly organization in comparison.

Why should we care? To quote Anderson, Reinhardt and colleagues, “It’s the prices, stupid!” In spite of the limited success of provider contracting, the private insurers have not been capable of adequately controlling price escalation, which is far greater than in all other nations – nations that depend on some sort of government role in establishing fair prices that cover costs and provide fair margins. We all pay more through higher insurance premiums when gougers are rewarded by the private insurers.

Seeing that everyone receives the care that they need, and controlling prices, are the most important functions that the private insurers should be carrying out. Yet they are doing neither competently. The defect is in the design of our health care financing system. The flaws in a system of competing private plans cannot be repaired. The private insurers will never have enough power, and even if they did, how would they use it? And those greedy health care providers who place business interests above professionalism will always be with us.

By replacing the private insurers with our own universal public financing program – an improved Medicare for all – we can include everyone, set prices at their proper level, and shut down the gougers. What are we waiting for?

More Aetna abuses, but wait, there’s worse

Aetna sued over out-of-network pay and referrals

By Alicia Gallegos
American Medical News, July 23, 2012

The California Medical Assn. and more than 50 physicians are suing Aetna over alleged retaliation against doctors who refer patients for out-of-network care.

The medical society and doctors say Aetna is underpaying out-of-network physicians, refusing to authorize some out-of-network services and illegally terminating the contracts of doctors who make such referrals.

The insurer’s practices violate California law and interfere with doctors’ medical decisions, said Long X. Do, CMA legal counsel.

The plaintiffs claim some of Aetna’s insurance policies enable patients to receive out-of-network care. However, Aetna discourages such practices and regularly refuses to pay for them, the suit claims.

Similarly, doctors’ contracts with Aetna do not specifically forbid all out-of-network referrals, the suit said. Yet, when doctors make such referrals, Aetna frequently threatens them with a “rate adjustment” or termination from Aetna’s network, according to the suit.

In a statement, Aetna spokeswoman Anjanette Coplin called the suit baseless and denied the insurer is mistreating physicians.

“Doctors who entice patients to have procedures performed at out-of-network facilities that they own without the patient’s knowledge are putting profits over their patients,” she said. “The wildly inflated bills of these facilities drive up the out-of-pocket costs for unwitting patients and needlessly add to premium costs for everyone.”

The CMA is aware of Aetna’s lawsuits, but said its suit has nothing to do with them. CMA’s claim centers on Aetna’s policies and practices, Do said.

http://www.ama-assn.org/amednews/2012/07/23/prsa0723.htm

And…

Silicon Valley Surgeons Risk ‘Moral Authority’ For 200% Returns

By Peter Waldman
Bloomberg, July 18, 2012

The anesthesiolgists’ ball in December 2010 was already raging when Dr. Thomas Elardo and his wife arrived. It was 11 p.m., and the Opera House in downtown Los Gatos, California, was packed with nurses and doctors dancing to ’80s covers by The Microbes, an all-doctor band. Elardo climbed the stairs to the mezzanine bar and was immediately gladhanded by Bobby Sarnevesht, a local entrepreneur, and orthopedist Samir Sharma, who pulled Elardo aside.

Elardo had known Sharma for years, but the orthopedist had never given him the time of day. That night was different — he had something to show Elardo. At the bar, Sharma flaunted a $960,000 check, Elardo recalls. Sharma said it was for his work as a surgeon and investor in an outpatient surgery center in Los Gatos, operated by Sarnevesht.

“They were saying, ‘This is the kind of money you can make. You’ve gotta come in!” recalls Elardo. “I was speechless.”

Founded by Sarnevesht and his mother, Julia Hashemieh, Bay Area Surgical Management has marshaled decades of doctor rage against insurance carriers into a profitable business.

By rejecting the discounted contracts that participating in-network providers sign with insurers, the surgery centers bill insurance companies at their own out-of-network rates, which are 5 to 35 times as much as the in-network facilities charge, and make a killing.

Knee arthroscopies that cost $3,000 in Aetna Inc. (AET)’s network earn nearly $20,000 in facility fees at Bay Area’s surgery centers, according to Aetna, the Hartford, Connecticut-based health insurer. A bunion repair that costs $3,700 in-network got almost $53,000 for Bay Area Surgical Group, one such center. A disc surgery for lower-back pain, called a laminectomy, costs about $6,000 in network yet reaps nearly $120,000 for Bay Area Surgical.

Fed up, Aetna sued Hashemieh and partners in February, claiming they gouge on rates, pay surgeons excessive compensation for referrals and defraud health plans.

http://www.bloomberg.com/news/2012-07-19/silicon-valley-surgeons-risk-moral-authority-for-200-returns.html

Comment: 

By Don McCanne, MD

Although it is always tempting to take on the abuses of private insurers such as Aetna, this time we should look further: the system by which we finance health care in the United States.

Perhaps the most important contribution of the private insurance industry in the past several decades has been the slowing of health care price increases through the process of provider contracting. Of course, public insurers such as Medicare are more effective, though through administered pricing rather than contracting. Nevertheless, health care prices would be even higher had the private insurers not engaged in contracting.

A problem that has never been satisfactorily resolved, in spite of many efforts, is what to do about charges by physicians and facilities that do not have contracts with the insurers – out-of-network providers. In some instances, the insurers pay nothing, except when required by law in certain emergency situations. In other instances, the insurers may pay at lower rates than they do for in-network providers, leaving the high balances as the responsibility of the patients. Often insurers will attempt to negotiate rates after the fact in order to prevent their clients from being stuck with these very high balances.

It is the latter situation that has become a problem. The Bloomberg article above (a very long, ugly story) goes into detail explaining how some entrepreneurial types in the health care delivery system have leveraged out-of-network care into a very lucrative operation. I dare say that Aetna looks like a saintly organization in comparison.

Why should we care? To quote Anderson, Reinhardt and colleagues, “It’s the prices, stupid!” In spite of the limited success of provider contracting, the private insurers have not been capable of adequately controlling price escalation, which is far greater than in all other nations – nations that depend on some sort of government role in establishing fair prices that cover costs and provide fair margins. We all pay more through higher insurance premiums when gougers are rewarded by the private insurers.

Seeing that everyone receives the care that they need, and controlling prices, are the most important functions that the private insurers should be carrying out. Yet they are doing neither competently. The defect is in the design of our health care financing system. The flaws in a system of competing private plans cannot be repaired. The private insurers will never have enough power, and even if they did, how would they use it? And those greedy health care providers who place business interests above professionalism will always be with us.

By replacing the private insurers with our own universal public financing program – an improved Medicare for all – we can include everyone, set prices at their proper level, and shut down the gougers. What are we waiting for?

Obamacare one step forward, one step back

By Philip Caper, M.D.
July 23, 2012

The affirmation of the constitutionality of the Patient Protection and Affordable Care Act, or Obamacare, on June 28 by the U.S. Supreme Court was a big step forward for our country. But parts of the act itself are a step in the wrong direction.

First, the steps forward. For the first time since the enactment of Medicare in 1965, the federal government has taken the position that health insurance should be extended to all Americans and that government has a major role to play in assuring this.

Obamacare aims to accomplish this goal by expanding public programs such as Medicaid and Community Health Centers, and requiring most Americans to buy private insurance or pay a tax penalty. These requirements are enabled by a variety of tax-funded subsidies to employers, employees and individuals.

To its credit, Obamacare also outlaws the most antisocial practices of private insurers — excluding people with a history of illness from coverage, charging outrageously high premiums if they’re sick or retroactively canceling coverage if a health insurance subscriber has the temerity to become ill and actually submit a claim.

But there was one especially troubling step backward that is the source of the unease felt by many health policy experts about the law.

Prior to Obamacare, our private for-profit insurance industry’s future was bleak. Facing the choice of satisfying Wall Street’s incessant demands for profitability or face declining stock prices, they were being forced into a death spiral of ever increasing premiums and ever harsher attempts to limit claims payments by denying services and otherwise restricting coverage to only those with the least probability of becoming ill. Those most vulnerable to illness were being left to fend for themselves.

By requiring tens of millions of healthy Americans to buy private health insurance with the help of federal subsidies, Obamacare has come to the rescue of corporate America once again. This insurance mandate gives the term “corporate welfare” a new and more robust meaning.

While I heartily applaud the intent of expanding health care to all, this means of doing so is actually destructive. From the perspective of our health care system as a whole, health insurance companies provide few if any benefits but do a lot of damage. By shoring up private for-profit health insurance, one of the most dysfunctional parts of our health care system, Obamacare will make health insurance companies much harder to get rid of.

And get rid of them we must. Private for-profit insurance is an extremely expensive and destructive way to expand coverage.

The private insurers’ administrative costs – e.g. money spent on underwriting, marketing, advertising, and big payouts to top executives and shareholders – siphon off 12 percent to 25 percent of our premium dollars. By comparison, the publicly funded Medicare program’s overhead is about 1.4 percent.

But it’s more than just a question of saving money. The U.S. system of private insurance also damages care. Insurers interfere directly with medical decisions involving individual patients. In addition, they so fragment our system of financing health care that they make much more difficult system-wide changes, such as reforming the way we pay doctors and hospitals and rationalizing the distribution of medical resources such as expensive technology.

Like other parasites (tapeworms, for example), health insurance companies don’t set out to do harm. It’s simply a byproduct of what they must do to achieve their primary mission — the creation of wealth for their owners. They’re doing what they must to survive and to thrive. They’re just the wrong tool to get the job done.

While Obamacare represents some progress and provides a platform for future improvements, it leaves much yet to be accomplished. To really have health care for everyone at a cost we can afford, we have to replace private for-profit insurance with nonprofit publicly administered insurance financed through a fair system of taxes. Only then will we have the tools to begin fairly and effectively to control overall system-wide costs, and improve the way medical care is delivered.

We are already paying more than enough for such a system and will continue to do so under Obamacare. It is estimated that the excess costs of relying on private insurance, all totaled, reach at least $400 billion a year in the U.S. — more than $1 billion dollars a year in Maine alone.

That’s a pretty expensive parasite. Removing parasites is often difficult for the doctor and unpleasant for the patient. But both feel a lot better when it’s done.

Physician Philip Caper of Brooklin is a founding board member of Maine AllCare, a nonpartisan, nonprofit group committed to making health care in Maine universal, accessible and affordable for all. He can be reached at pcpcaper21@gmail.com.

PNHP note: The article above is a slightly revised version of the original, which appeared in the July 20 edition of the Bangor Daily News and which can be found here.