PNHP

Dr. Glaucomflecken Doctor Visit in Another Country

Dr. Glaucomflecken Doctor Visit in Another Country

Summary: The unique tragedy of an expensive and ineffective US health system is summed up in a quick, hilarious sketch. Brilliant! Humor for social change is so powerful. Share widely.

An American Experiences Universal Healthcare, Dr. Glaucomflecken, Twitter (2 minute video), July 12, 2022

Comment:

By Jim Kahn, M.D., M.P.H.

So funny! I smile each time I listen.

And, so concisely capturing how stunningly abysmal our health system is compared with other nations. I frown when I contemplate that.

Let’s finally join the rest of the wealthy world, with generous, anxiety-reducing, healthy, and inexpensive universal health coverage. Single payer.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

America Was in an Early-Death Crisis Long Before COVID

Even before the pandemic began, more people here were dying at younger ages than in comparably wealthy nations.

By Ed Yong
The Atlantic, July 21, 2022

Jacob Bor has been thinking about a parallel universe. He envisions a world in which America has health on par with that of other wealthy nations, and is not an embarrassing outlier that, despite spending more on health care than any other country, has shorter life spans, higher rates of chronic disease and maternal mortality, and fewer doctors per capita than its peers. Bor, an epidemiologist at Boston University School of Public Health, imagines the people who are still alive in that other world but who died in ours. He calls such people “missing Americans.” And he calculates that in 2021 alone, there were 1.1 million of them.

Bor and his colleagues arrived at that number by using data from an international mortality database and the CDC. For every year from 1933 to 2021, they compared America’s mortality rates with the average of Canada, Japan, and 16 Western European nations (adjusting for age and population). They showed that from the 1980s onward, the U.S. started falling behind its peers. By 2019, the number of missing Americans had grown to 626,000. After COVID arrived, that statistic ballooned even further—to 992,000 in 2020, and to 1.1 million in 2021. Were the U.S. “just average compared to other wealthy countries, not even the best performer, fully a third of all deaths last year would have been prevented,” Bor told me. That includes half of all deaths among working-age adults. “Think of two people you might know under 65 who died last year: One of them might still be alive,” he said. “It raises the hairs on the back of my neck.”

Graph of excess American Deaths from 1940 to 2020

These counterfactuals puncture two common myths about America’s pandemic experience: that the U.S. was just one unremarkable victim of a crisis that spared no nation and that COVID disrupted a status quo that was strong and worth restoring wholesale. In fact, as one expert predicted in March 2020, the U.S. had the worst outbreak in the industrialized world—not just because of what the Trump and Biden administrations did, but also because of the country’s rotten rootstock. COVID simply did more of what life in America has excelled at for decades: killing Americans in unusually large numbers, and at unusually young ages. “I don’t think people in the United States actually have any awareness of just how poorly we do as a country at letting people live to old age,” Elizabeth Wrigley-Field, a sociologist at the University of Minnesota, told me.

Although Bor’s study has yet to be formally reviewed, Wrigley-Field and five other independent researchers vouched for its quality to me. “The paper is extremely important, and the researchers who produced this know what they’re doing,” Steven Woolf, a population-health expert at Virginia Commonwealth University, told me. “It builds on, and considerably expands, what we’ve already known.”

Several studies, for example, have shown that America’s life expectancy has tailed behind other comparable countries since the 1970s. By 2010, that gap was already 1.9 years. By the end of 2021, it had grown to 5.3. And although many countries took a longevity hit because of COVID, America was once again exceptional: Among its peers, it experienced the largest life-expectancy decline in 2020 and, unlike its peers, continued declining in 2021. But Bor says that people often misinterpret life-expectancy declines, as if they simply represent a few years shaved off the end of a life. Someone might reasonably ask: What’s the big deal if I die at 76 versus 78? But in fact, life expectancy is falling behind other wealthy nations in large part because a lot of Americans are dying very young—in their 40s and 50s, rather than their 70s and 80s. The country is experiencing what Bor and his colleagues call “a crisis of early death”—a long-simmering tragedy that COVID took to a furious boil.

In every country, the coronavirus wrought greater damage upon the bodies of the elderly than the young. But this well-known trend hides a less obvious one: During the pandemic, half of the U.S.’s excess deaths—the missing Americans—were under 65 years old. Even though working-age Americans were less likely to die of COVID than older Americans, they fared considerably worse than similarly aged people in other countries. From 2019 to 2021, the number of working-age Americans who died increased by 233,000—and nine in 10 of those deaths wouldn’t have happened if the U.S. had mortality rates on par with its peers. “This is a damning finding,” Oni Blackstock, the founder and executive director of Health Justice, told me.

Graph of mortality rates for age groups 0-80 in 1933, 1960, 1980, 2000, 2019, 2020, and 2021

The crisis of early death was evident well before COVID. As many studies and reports have shown, since the turn of the 21st century, “midlife ages are where health and survival in the U.S. really go off the rails,” Wrigley-Field told me. “The U.S. actually does well at keeping people alive once they’re really old,” she said, but it struggles to get its citizens to that point. They might die because of gun violence, car accidents, or heart disease and other metabolic disorders, or drug overdoses, suicides, and other deaths of despair. In all of these, the U.S. does worse than most equivalent countries, both by failing to address these problems directly and by leaving people more vulnerable to them to begin with.

Consider how many years the missing Americans would have collectively enjoyed had they survived—all the birthdays and anniversaries that never happened. In other rich countries, the total “years of life lost” have flatlined for the past five decades. In the U.S., they have soared: In 2021 alone, the 1.1 million missing Americans lost 25 million years of life among them. That number doesn’t account for the events that preceded many of these deaths—the “years of disability, illness, and loss of human potential, creativity, and dignity,” Laudan Aron, a health-policy researcher at the Urban Institute, told me. And, especially in the case of middle-aged deaths, they left behind young dependents, whose own health might suffer as a result. The sheer number of missing Americans, and the “profound ripple effects” of their absence, are “really hard to wrap one’s head around,” Aron said.

Graph of expected and actual years of life lost in the United States from 1940 to 2020

These staggering numbers also help contextualize COVID’s toll. The coronavirus caused the largest single-year rise in mortality since World War II, becoming the third leading cause of death in the U.S., after only heart disease and cancer. But this enormous tragedy unfolded against an already tragic backdrop: The number of missing Americans from 2019 is larger than the number of people who were killed by COVID in 2020 or 2021. This isn’t to minimize COVID’s impact; it simply shows that in the Before Times, America had “very successfully normalized to an extremely high level of death on the scale of what we experienced in the pandemic,” Justin Feldman, a social epidemiologist at Harvard, told me. And when COVID drove those levels skyward, America proved that “we’ll accept even more deaths compared to our already poor historical norms,” Feldman said.

Such deaths, though obvious on a graph, are hidden from Americans with social privilege. In the summer of 2020, Bor remembers having an outdoor BBQ with a friend who grew up in a low-income housing project. “At that point, six months in, he knew six people in his close circle who had been killed by COVID,” Bor told me. “I still don’t.” The fact that half of the working-age Americans who died last year should still be alive “isn’t visceral if you haven’t lost anyone,” he said.

The current mortality crisis was long in the making. In terms of mortality, America’s peer countries—many of which had been hammered by World War II and its aftermath—began catching up with it in the mid-1970s before overtaking in the early 1980s. That was a pivotal era, when globalization, automation, and a growing service industry led to huge losses in mining, manufacturing, and other blue-collar sectors. The U.S. profoundly failed to protect its citizens from these changes. Its social safety net—state assistance for parents, or people facing job, food, or housing insecurity—was meager; its public-health system was languishing after decades of underinvestment; and unlike every other wealthy country, it lacked universal health care. These factors “privatized risk,” Bor and his colleagues wrote in their paper, “tying health more closely to personal wealth and employment.” As labor unions declined and minimum wages stagnated, more Americans had fewer resources to lean on if their health declined. Poorer Americans already lived, on average, shorter lives than rich ones, and that gulf started to widen.

Other particularly American choices exacerbated the stresses on the health of the country’s citizens, again weighing more heavily on less wealthy people. A growing mass-incarceration industry punished them. A deregulatory agenda that began with Ronald Reagan’s administration left them vulnerable to unhealthy foods, workplace hazards, environmental pollutants, guns, and opioids. “America basically says: If you’re poor, you don’t have access to safe choices,” Bor told me.

Factors like social inequalities and frayed social safety nets are the fundamental weaknesses of American society, which more specific problems like opioids, metabolic disorders, and COVID exploit. During the pandemic, for example, poor and minority groups were more likely to be infected because they lived in crowded housing, distrusted medical leaders, and couldn’t work from home or take time off when sick. And instead of addressing these foundational problems, policy makers instead focused on personal responsibility.

America’s drastic underperformance in health also stems from its history of segregation and discrimination. Racist policies have obviously harmed the health of minorities. But as the policy expert Heather McGhee and the physician Jonathan Metzl have independently argued, elites have long marshaled the racial resentment of poor white Americans to undermine support for public goods that would benefit everyone, such as universal health care. Per Frederick Douglass and other Black leaders, “They divided both to conquer each.”

COVID, for example, disproportionately killed Black, Latino, and Indigenous Americans—a trend that, when highlighted to white people, reduces their concern about the pandemic and their support for safety measures. But in 2021, young white Americans still died at three times the rate of the average resident of other peer nations, while young Black and Indigenous Americans died at rates five- and eightfold higher, respectively. “There are thousands of racial-disparity studies that compare Black people to white people—but white Americans are a terrible counterfactual,” Bor told me. They’re frogs in the same pot, boiling more slowly but boiling nonetheless. By using them as a baseline, we ignore how “everyone is harmed by the status quo in the U.S.,” Blackstock told me, while also underestimating how dire things really are for people of color. (The same problem applies to income inequality: White Americans living in the richest 1 percent of counties still have higher rates of maternal and infant mortality than the average residents of wealthy countries.)

So, “what happens now?” Bor asked me. “Are we going to have 1 million missing Americans a year, every year, going forward? Or more?” His study doesn’t suggest a reason for optimism, but it does provide a defense against nihilism. The entire concept of missing Americans is rooted in a comparison with other countries, which shows that these early deaths aren’t inevitable. The U.S. could at least start moving in the direction of its peers by adopting policies that work elsewhere, such as universal health care, minimum-wage increases, federally required paid sick leave, and better unemployment insurance.

But “the inability of our politics to generate policies that manage health threats is grim,” Bor said. None of the weaknesses that COVID exposed have been addressed; some, like the chasm-sized health gaps between rich and poor or white and Black, have been widened. Vaccines significantly reduce the risk of dying from COVID, but their power is blunted by low uptake, new variants, the lifting of almost all infection-thwarting protections, and the looming loss of COVID funding. Reactionary laws that hamstring what public-health departments can do in emergencies will make the U.S. vulnerable to the new viruses that will inevitably assault it in future years. America’s already underperforming health-care system has been badly battered by the pandemic, and weakened by waves of health-care-worker resignations. In recent months, the Supreme Court has constrained both gun and carbon-emission regulations, while clearing the road for states to restrict or ban abortions—a move that could easily boost America’s already sky-high maternal mortality rates. The climate is still changing rapidly, exposing people who have no choice but to work outside to the ravages of heat.

As much of the country returns to normal, Bor’s study makes plain what normal actually meant—and, as I wrote in 2020, that normal led to this. “A lot of Americans may be under the impression that we had a bad go of it during COVID, and once the pandemic is over, they can go back to having the best health in the world,” Woolf told me. “That is a gross misconception.”

https://www.theatlantic.com…

Medicaid Coverage Does Not Assure Access to Care

Summary: Coverage with Medicaid – health insurance for the poor – increased in recent years. But as a new study reveals for cancer, coverage does not guarantee access to cancer centers, due to low reimbursement rates, clunky administration, and narrow provider networks. These operational flaws are well-known and politically tolerated in Medicaid, despite the more equitable and efficient solution of high quality insurance for everyone – single payer.

Acceptance of Simulated Adult Patients with Medicaid Insurance Seeking Care in a Cancer Hospital for a New Cancer Diagnosis, JAMA Network Open, July 15, 2022, by Victoria A. Marks … Michael S. Leapman

Key Points:

Question: Can individuals insured by Medicaid access cancer care services at high-performing cancer-designated hospitals?

Findings: In this cross-sectional study of 334 facilities recognized for cancer care, 95.5% accepted new patients with Medicaid for breast cancer, 90.4% for colorectal cancer, 86.8% for kidney cancer, and 79.6% for skin cancer (melanoma) care. Medicaid was accepted for all 4 surveyed cancers at 67.7% of facilities.

Meaning: Despite increases in the number of US residents insured through Medicaid, these findings suggest that barriers to accessing cancer care exist at high-quality centers.

For Medicaid-Insured Patients with Cancer, Health Insurance Does Not Always Mean Health Access, Press Release, Yale School Medicine, July 15, 2022

“We found that Medicaid acceptance differed widely across cancer care facilities, with a substantial number of centers not offering services to patients with Medicaid insurance,” said Michael Leapman, MD, MHS, Associate Professor of Urology, Clinical Program Leader for the Prostate & Urologic Cancers Program at Yale Cancer Center and Smilow Cancer Hospital, and senior author on the study.

“This study underscores that having health insurance alone does not necessarily mean that patients can practically access healthcare. While major recent expansions of Medicaid have led to increases in health insurance coverage for Americans with cancer, we have to be aware and do more to ensure that insurance will actually translate to timely and high-quality care,” said Dr. Leapman.

“Despite a large increase in the number of Medicaid-insured patients, most factors that limit a hospital or physician’s participation in Medicaid have not changed,” he said. “These include low reimbursement, high administrative burden, and limited specialist participation in managed care organization networks.”

Comment:

By Don McCanne, M.D.

One of the successes touted by the proponents of the Affordable Care Act has been the increases in the numbers enrolled in the state Medicaid programs. Many support further expansion of Medicaid. But, as this study confirms, even for high-performing centers, access is often impaired for those covered by Medicaid, with persistence of “low reimbursement, high administrative burden, and limited specialist participation in managed care organization networks” being contributing factors.

Amongst other features, we really do need a health care financing system that is universal, comprehensive, and equitable. We are not going to find that in Medicaid – health insurance for the poor, with substandard performance. For those politicians who keep talking about expanding Medicaid, they are finally going to have to concede that the real answer is in single payer.

Besides, until then, how do the administrative personnel in these high-performing centers sort out Medicaid patients with cancer to decide which are to be sent to the door marked “Exit?”

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Value-Based Care Will Bring Value to Shareholders

Summary: Building on an inauspicious decade of failed efforts to improve care or save money for Medicare, value-based care is now the darling of CMS and scores of private companies involved in its latest incarnation, REACH. Health and equity rhetoric aside, it’s all about profits for investors. Greed dressed up to be presentable in public.

Value-Based Care is a Pretext for Privatization, Counterpunch, July 13, 2022, by Kay Tillow

Later this month, right before Medicare’s 57th birthday on July 30, corporate health care and the government players who facilitate their lucrative businesses, will gather for a summit on value-based care. They will speak of driving health equity, of reaching underserved communities, of coordination of care, and accountable care. They will insist that physicians share in risk just like insurance companies. They will advocate the transformation of health care to value-based care, supposedly founded on payment for quality rather than quantity, value instead of volume, and outcomes not fee-for-service.  They will assert that this transformation brings equity, improves care, and saves money. …

While the [Center for Medicare and Medicaid Innovation] projects have not proven to enhance quality nor to save money, they are very successful at the hidden goal—the insertion of private profit-makers into the health care system and the privatization of Medicare and Medicaid.

Comment:

By Ana Malinow, M.D.

On the eve of Medicare’s 57th Birthday, no fewer than five former Administrators of the Centers for Medicare and Medicaid Services (CMS), three of the biggest medical professional societies, almost a dozen academic institutions, influential health policy think tanks, and over 30 corporations will convene to save our sinking primary care ship using value-based care. But like a lifesaver full of holes, value-based care will prove to be another dud unable to control costs and improve care. Worse than that, as Kay Tillow brilliantly wrote last week, “value-based care is a pretext for privatization.” Tillow connected all the dots, naming names, uncovering links, and exposing the players who are set to dole out public dollars for private gain.

The lifeline we are tossed is ACO REACH, the latest invention out of the Center for Medicare and Medicaid Innovation. HJM has pointed out fundamental problems with REACH: excess profit, paltry equity efforts, and impaired physician-patient trust among them.

REACH promises to bring value-based care to all of Medicare by 2030. As Tillow points out, this will not address the ineffectiveness of a system that led to 339,000 unnecessary COVID deaths nor combat the low US life expectancy compared to peer countries during the COVID pandemic. Value-based care, for all its aspirations to achieve equity, will not make a dent in our highly racialized decrease in life expectancy. While American life expectancy decreased by 2.41 years during the first two years of the pandemic, American Indian/Alaska Native individuals lost almost 5 years, making the life expectancy of AIAN men in the US, low before the pandemic, now comparable to that of men living in Afghanistan.

How are these players suggesting we transform primary care? Listen to a series of 15 “market movers,” all of which target senior care and are Direct Contracting Entities (soon to be ACO REACH), tech platforms to enhance value-based care, underwriters of the delivery of value-based care, or otherwise involved in helping primary care providers earn additional revenue. At least 14 of the 15 movers are publicly traded or investor owned. Or sit down for a fireside chat (end of July, no thanks!) with two companies, one publicly traded and another one backed by venture capital, focusing on delivering care to the underserved. Or take in a seminar on driving equity in primary care with Chief Innovation Office of One Medical, funded by Carlyle Group. Or learn about partnerships with private equity. Or listen to health care disruptors Google, Walgreens, and Amazon.

If you don’t think value-based care is all about privatization, think again. As Tillow writes, this “upcoming corporate extravaganza” will sink us for good.

Instead of privatizing the health care system, we should be organizing for a national, single payer program. That’s the lifeline we need.

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare REACH: Financial Incentives will Undermine Doctor-Patient Trust

Summary: Hidden in the fine print of the REACH program launched by CMS to transform traditional fee-for-service Medicare we discover a pivotal, nasty feature: Physicians will share in the financial savings achieved by capitated contractors. This destroys more than 50 years of beneficiary confidence that doctors’ decisions are based on their best medical interests.

ACO Realizing Equity, Access, and Community Health (REACH) Model Request for Applications, Centers for Medicare & Medicaid Services (CMS), February 24, 2022

All Participant Providers and Preferred Providers … may receive a distribution from the ACO of any shared savings payment received by the ACO …

ACO REACH Model PY2023 Participant and Preferred Provider Management Guide, Centers for Medicare & Medicaid Services (CMS), Revised June 2022

Comparing GPDC to the ACO REACH Model, Centers for Medicare & Medicaid Services (CMS), February 2022

A very detailed table, to explain REACH to the public. However, NO mention of sharing savings with providers.

Comment:

By Jim Kahn, M.D., M.P.H.

I’ve focused on various problems that will plague REACH, most recently the leeway permitted for fast diagnostic upcoding and thus rapid profit growth.

Then, the worst feature of all, hiding in the program details, jolted me: REACH is structured to make doctors complicit in the money game. Specifically, they can receive a portion of the “shared savings” generated when their patients use fewer Medicare resources than the capitation amount. With a discount imposed on their regular fees, the pressure to reduce care and thus recoup income is immense.

To be crystal clear: when doctors reduce or delay care, by skipping diagnostic tests or referrals to specialists or treatments, and their patients spend less overall, doctors get a financial bonus by receiving a portion of the savings.

And when doctors participate in diagnostic upcoding, they share in the resulting increased savings under the higher capitation level.

With REACH contractors permitted to keep ALL of the first 25% in savings, the incentive to reduce care is powerful. And with doctors eligible to receive a slice of those savings, clinical decisions will have two competing masters: patient well-being and provider income.

So, for nearly six decades, traditional Medicare beneficiaries could count on doctors to focus on their well-being, with no incentive to save (or, with the early ACOs, a very small incentive).

This central program feature is spelled out in contractor documents (request for proposal, program guidance), but not mentioned in the CMS material disseminated to the public. I think I know why: CMS knew it would be hugely unpopular.

We need to save traditional Medicare, by ending REACH and removing for-profit intermediaries and the co-opting of physicians. We need to focus on patient welfare. We need single payer!

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Medicare for All Explained Podcast: Episode 81

Little Things That Can Make a Difference

July 15, 2022

Podcast host Joe Sparks talks about the administrative headaches associated with U.S. medical records, and the demands these records place on patients, especially those who are seeing a new doctor or visiting a new medical facility.

He notes how entering and re-entering medical history and other data “takes quite a bit of time, and causes me to see how many cuss words I know.”

Additional episodes will be uploaded twice monthly. Subscribe in iTunes, or access a complete archive of the podcast, below.

https://medicareforallexplained.podbean.com

REACH Won’t Fix the Equity Harms of Value-Based Care

Summary: A commentary in the New England Journal of Medicine by individuals consulting for huge health care companies argues that REACH, the new corporate-focused funding mechanism for traditional Medicare, will enhance equity. Their assertion is hype, with no evidence. Single payer would guarantee equity.

“REACHing” for Equity—Moving from Regressive toward Progressive Value-Based Payment, New England Journal of Medicine, July 9, 2022, by S Gondi, K Joynt Maddox, & R Wadhera

Comment:

By Ana Malinow, M.D.

Even before the Center for Medicare and Medicaid Innovation (CMMI) rebranded the Global and Professional Direct Contracting model as ACO REACH, requiring “all model participants [to] develop and implement a robust health equity plan to identify underserved communities and implement initiatives to measurably reduce health disparities within their beneficiary populations,” the industry had been flagellating itself over its lackluster equity outcomes. The authors explain why value-based care payments, the darling of health policy experts, have failed so miserably to address health equity.

Just what is value-based care (VBC)? Good luck finding a definition to this slippery term. Mostly, it is defined in terms of its goals, as in this article, published in the New England Journal of Medicine Catalyst, that describes the VBC model as one where hospitals and physicians are paid and rewarded on patient outcomes while controlling costs. Benefits for patients include spending less money to achieve better health; for providers, achieving efficiencies and greater patient satisfaction; for payers, controlling costs and reducing risk; for suppliers, aligning price with patient outcomes; and for society, becoming healthier while reducing overall spending.

There is no shred of evidence that this has ever happened or ever could. The New England Journal of Medicine Catalyst Innovations in Care Delivery, a recent peer-reviewed project of NEJM Catalyst, publishes articles which “are vetted rigorously and are evaluated for originality, innovation, readability, clarity, relevance… practicability and scalability.” Evidence is not mentioned. All aspiration and fluff. The Catalyst offers “exclusive sponsorship opportunities for organizations that recognize the value of joining an industry dialog while aligning their brand and solutions with influential NEJM Catalyst audiences.” A dangerous alliance for the venerable NEJM.

To pay based on value, one should define value. But defining and measuring value in medicine and rewarding or punishing the physician for creating or failing to create value are elusive because: 1) there are over 85,000 CPT service codes, making it difficult if not impossible to decide which value to measure; 2) inevitably, services not chosen receive less attention; 3) patients see multiple providers every year despite being assigned to one PCP; and 4) most of the determinants of health are outside the control of the physician.

The authors of “REACHing for Equity,” one of whom consults for the Centene Corporation, the largest Medicaid managed care organization in the U.S. [KJM], and the other for the giant CVS Health [RKW], honestly admit to the many flaws of VBC, including:

  1. Disproportionally penalize outpatient clinicians who care for poor adults through Medicare’s Merit-Based Incentive Payment System (MIPS).
  2. Transfer resources away from safety-net hospitals and potentially widening inequities in care through all Medicare’s hospital value-based programs.
  3. Perpetuate structural racism by penalizing institutions caring for high proportions of Black adults.
  4. Reward practices and hospitals with robust infrastructure that can adapt to logistic and reporting requirements (draining resources from needier practices and hospitals).
  5. Set up unrealistic expectations for providers with patients who use fewer resources due to lack of services, putting them at a disadvantage.
  6. Encourage gaming the system by avoiding high-utilizing patients and widening long-standing racial disparities.
  7. Encourage gaming the system of well-resourced providers who maximize their scores based on their existing performance without improving care.
  8. Punish providers who care for low-income populations who often have fewer resources to dedicate to score optimization.
  9. Encourage upcoding.
  10. Strategically drop high risk beneficiaries or clinicians whose panels consist of large numbers of these patients to reduce spending and increase their chances of earning shared savings.

One would think 10 well-referenced reasons would be enough to put this model, which has exacerbated health inequities, to rest, but no. They argue that VBP has failed to advance health equity because equity wasn’t prioritized. And that’s where ACO REACH will be different. Because this new model will prioritize equity (while keeping everything else the same), equity will be achievable. How?

First, the new model includes a new “health equity benchmark adjustment” and will pay providers who care for underserved patients $30/month/beneficiary in the top decile of disadvantage and a downward adjustment for providers not caring for the underserved. This is supposed to entice providers to care for underserved beneficiaries. But providers get this payment even if the beneficiaries do not receive any services to address health inequities. We are made to believe this $30 adjustment should be enough to transfer resources back into safety-net hospitals and physicians.

Second, providers are supposed to fill out a health equity plan. These plans are supposed to use “payment reform as a lever to foster local efforts that promote equity,” but the equity plan is a 5-step boilerplate created by the CMS Office of Minority Health, reminiscent of a 5th grader’s attempt at QI. Other efforts by CMS to “promote health equity” include the CMS Health Equity Awards, which in 2020 went to UnitedHealthcare. A previous award recipient was the Centene Corporation. CMS would like us to put our hopes on corporations to address structural racism.

Third, REACH models are supposed to collect and submit data on demographics and social determinants of health, to the extent that beneficiaries are willing. Figuring out how to define and measure social risk adjusters, just like value, will spawn a whole new cottage industry, creating another level of middlemen. Thus, mandating data collection without mitigating any inequities should be sufficient to counter gaming the system.

Really?

Value-based payment has been an invention peddled by policy elites through peer-reviewed publications. Some of those policy experts now admit that VPC is regressive. However, instead of taking these “lessons learned” and recommending the model be scrapped altogether, they propose to expand it to include “equity” and make it mandatory – with no evidence it will work.

In addition to medical outcomes, as well as to the day-to-day financial responsibility of risk-sharing arrangements, physicians will now be responsible for the equity outcomes of their patients. What’s next? Inflation? Arguing against VBC, Lisa Rosenbaum wrote also in NEJM that doctors want the best care for their patients. Tying financial incentives, and the documentation burden that is involved, to value, cost and now equity, has already harmed and will prove fatal to the profession and to patients.

Why not model national single payer, known to increase value, equity, and lower costs around the world? Or are the sponsors of our models too beholden to the profiteers to offer real progressive change?

http://healthjusticemonitor.org…

Stay informed! Subscribe to the McCanne Health Justice Monitor to receive regular policy updates via email, and be sure to follow them on Twitter @HealthJustMon.

Missing Americans: Early Death in the United States, 1933-2021

By Jacob Bor, Andrew C. Stokes, Julia Raifman, Atheendar Venkataramani, Mary T. Bassett, David Himmelstein, and Steffie Woolhandler
PNAS Nexus, July 12, 2022

Abstract: We assessed how many U.S. deaths would have been averted each year, 1933-2021, if U.S. age-specific mortality rates had equaled those of other wealthy nations. The annual number of excess deaths in the U.S. increased steadily beginning in the late 1970s, reaching 626,353 in 2019. Excess deaths surged during the COVID-19 pandemic. In 2021, there were 1,092,293 “Missing Americans” and 25 million years of life lost due to excess mortality relative to peer nations. In 2021, half of all deaths under 65 years and 91% of the increase in under-65 mortality since 2019 would have been avoided if the U.S. had the mortality rates of its peers. Black and Native Americans made up a disproportionate share of Missing Americans, although the majority were White.

One-sentence summary: In 2021, 1.1 million U.S. deaths – including 1 in 2 deaths under age 65 years – would have been averted if the U.S. had the mortality rates of other wealthy nations.

full text:
https://www.medrxiv.org…

US Health Insurance Cost-Sharing Benefits Insurers & Harms the Rest of Us

Summary: A chief health officer and pediatrician at Indiana University speaks plain and powerful truth about growing insurance cost-sharing – it’s designed to reward insurers, to the health and financial detriment of the insured.

What’s Wrong With Health Insurance? Deductibles Are Ridiculous, for Starters, New York Times, July 7, 2022, by Aaron E. Carroll

More than 100 million Americans have medical debt, according to a recent Kaiser Health News-NPR investigation. And about a quarter of American adults with this debt owe more than $5,000.

The Affordable Care Act was supposed to improve access to health insurance, and it did. Unfortunately, it has not done enough to protect people from rising out-of-pocket expenses in the form of deductibles, co-pays and co-insurance.

This moral-hazard argument assumes that patients are rational consumers, and it assumes that cost-sharing in the form of deductibles and co-pays makes them better shoppers. Research shows this is not the case.

People are not smart shoppers or rational spenders when it comes to health care. When you make people pay more, they consume less care, even if it’s for lifesaving treatment.

The average deductible on a silver-level plan on the A.C.A. exchanges rose to $4,500 in 2021.

Those who receive insurance from their employers aren’t much better off than those who buy on the A.C.A. marketplaces. The average deductible for insurance offered by large companies in the United States was more than $1,200.

Those are only the deductibles. After they are paid, people must still cover co-pays and co-insurance until they hit the out-of-pocket maximums. The good news is that the A.C.A. limits these in plans sold in the exchanges. The bad news is that they’re astronomical: $8,700 for an individual and $17,400 for a family. A large majority of Americans don’t have that kind of money sitting in accounts, certainly not after paying an average of about $5,000 in premiums each year for a benchmark individual silver plan.

The purpose of insurance is to protect people from financial ruin if they face unexpected medical expenses. Reducing the amount that they need to pay from six figures to five is necessary, but not sufficient. It’s not enough to give people insurance.

Aaron E. Carroll is the chief health officer for and a distinguished professor of pediatrics at Indiana University.

Comment:

By Don McCanne, M.D.

For many decades we’ve recognized we have a very serious problem. We have a very expensive health care system which exposes far too many to significant medical debt because our fragmented, dysfunctional health insurance system has been inadequate to provide the financial protection that patients need.

It seems obvious that we need to provide as a solution a system that provides health care access to the patient – all patients – without exposing them to medical debt. But instead of looking for a solution that takes care of the problems of patients, we have been looking for solutions that take care of the problems of the insurer.

Thus we have perpetuated the moral-hazard argument: make the patient feel the financial pain of the health care they are about to consume so that costs to the insurer will be reduced by eliminating superfluous care. Well, we know what that does: it results in skipped necessary care and impaired health outcomes, even death, and it results in medical debt because of the direct charges the insurer passes on to the patient – both the opposite of what a health care financing system should be achieving.

Dr. Carroll’s proposed solutions would modify current health care financing, e.g., by offering better insurance for the chronically ill and reference pricing for drugs and procedures. His solutions are piecemeal, subject to gaming, and inadequate.

Suppose all of these decades we had been looking for solutions that took care of our target –patients – rather than a marketplace intermediary – insurers, what would these solutions look like? Well, they would provide health care access to absolutely everyone without burdening them with medical debt. Instead of reducing spending by erecting financial barriers to patient care, we would reduce spending by eliminating this very expensive, administratively complex insurance industry and its investors.

For decades we’ve known that a publicly administered single payer system is what we clearly need, yet we have continued to privatize even our existing public programs such as Medicare and Medicaid to the benefit of private equity rather than to the benefit of patients.

So why do we keep electing legislators and an administration that take care of the superfluous, dysfunctional, egregiously wasteful insurance industry when we want them instead to take care of the health care needs of the people?

http://healthjusticemonitor.org…

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Oh So Many Problems with Medicare Advantage

Summary: A news article reports on Congressional hearings on problems with Medicare Advantage. An academic article describes big challenges and valuable public benefits lost if traditional Medicare is replaced by Medicare Advantage. Our apologies for a longer-than-usual post … too many Medicare Advantage failings to review!

(HJM bolding for key points)

Government Watchdogs Attack Medicare Advantage for Denying Care and Overcharging, KHN, June 29, 2022, by Fred Schulte

Congress should crack down on Medicare Advantage health plans for seniors that sometimes deny patients vital medical care while overcharging the government billions of dollars every year, government watchdogs told a House panel Tuesday.

Witnesses sharply criticized the fast-growing health plans at a hearing held by the Energy and Commerce subcommittee on oversight and investigations. They cited a slew of critical audits and other reports that described plans denying access to health care …

Rep. Diana DeGette (D-Colo.), chair of the subcommittee, said seniors should not be “required to jump through numerous hoops” to gain access to health care.

The watchdogs also recommended imposing limits on home-based “health assessments,” arguing these visits can artificially inflate payments to plans without offering patients appropriate care. …

Bliss said seniors “may not be aware that they may face greater barriers to accessing certain types of health care services in Medicare Advantage than in original Medicare.”

Leslie Gordon, of the Government Accountability Office, the watchdog arm of Congress, said seniors in their last year of life had dropped out of Medicare Advantage plans at twice the rate of other patients leaving the plans.

Rep. Frank Pallone Jr. (D-N.J.), who chairs the influential Energy and Commerce Committee, said he was “deeply concerned” to hear that some patients are facing “unwarranted barriers” to getting care.

James Mathews, who directs the Medicare Payment Advisory Commission, which advises Congress on Medicare policy, said Medicare Advantage could lower costs and improve medical care but “is not meeting this potential” despite its wide acceptance among seniors.

Notably absent from the hearing witness list was anyone from CMS, which runs the $350 billion-a-year program.

[CMS] officials clearly knew years ago that some health plans were abusing the payment system to boost profits yet for years ran the program as what one CMS official called an “honor system.”

CMS aimed to change things starting in 2007, when it rolled out an audit plan called “Risk Adjustment Data Validation,” or RADV. Health plans were directed to send CMS medical records that documented the health status of each patient and return payments when they couldn’t.

The results were disastrous, showing that 35 of 37 plans picked for audit had been overpaid, sometimes by thousands of dollars per patient. Common conditions that were overstated or unable to be verified ranged from diabetes with chronic complications to major depression.

Yet CMS still has not completed audits dating as far back as 2011, through which officials had expected to recoup more than $600 million in overpayments caused by unverified diagnoses.

Medicare Advantage Enrollment Growth Implications for the US Health Care System, JAMA, June 28, 2022, by Gretchen Jacobson & David Blumenthal

Medicare Advantage will be the dominant source of Medicare coverage by 2025. This development creates significant challenges ….

[T]he need to find new ways to set Medicare Advantage payment rates. Currently, Medicare Advantage plans in local markets are paid to cover Medicare benefits based on the average costs of providing those same benefits to patients in traditional Medicare within the same market. Yet, basing payments on the costs of covering remaining enrollees in traditional Medicare will be less appropriate as these individuals become less and less representative of the Medicare population…

[P]otential loss of the vital role that traditional Medicare has had in shaping the health care system generally. Traditional Medicare has led the way in developing quality standards and measures that have been widely applied and in transparently sharing results with the public.

[T]raditional Medicare claims data provide the only nationwide source of consistent, comparable information on patterns of care throughout the country. … have enabled important observations about variability in care within and across geographic areas, and have informed policies to reduce variation, reduce unnecessary spending, and improve the quality of care.

[T]raditional Medicare has helped support rural health care centers and fund graduate medical education. …

[Q]uality and utilization data that traditional Medicare has accumulated on individual clinicians and health care centers are not currently accessible for those same entities serving patients enrolled in Medicare Advantage plans. … Medicare Advantage organizations and their clinicians and health centers are not reimbursed based on encounter data, and thus do not have the same incentives to submit complete and accurate information.

A Medicare Advantage–dominated system also raises questions about how Medicare would work through private plans to achieve the many other public purposes that Medicare has served. Traditional Medicare’s increased payments for clinicians and health care centers in rural areas have helped to maintain access to care for rural populations.

… looming challenges created by the impending transformation of Medicare into a system primarily consisting of competing for-profit health organizations. … [and] consider how to compensate for the vital information about the US health care system that could be lost with the decline of traditional Medicare. …

[C]onsider how to sustain Medicare’s record of innovation in payment and delivery system reform in a program in which the nature and results of innovation are increasingly the proprietary property of private entities. CMMI will have to develop methods to take full advantage of a much more modest traditional Medicare testing ground. Medicare also will have to consider whether and how to incentivize or encourage private organizations to share their most promising innovations— undertaken with public funds—so that Medicare can fulfill its obligations to all beneficiaries and, as a public program, to the health care system generally.

Comment:

By Jim Kahn, M.D., M.P.H.

Two unrelated reports on problems with Medicare Advantage, the private insurer side of Medicare:

KHN (Kaiser Health News) lists Medicare Advantage problems discussed in a Congressional hearing: care barriers and denials; excess home health assessments designed to inflate capitation payments; audits revealing widespread overpayment yet languishing >10 years; patients switching to traditional Medicare at the end of life when medical needs rise; Medicare Advantage failing to realize purported advantages; CMS missing in action (and from the hearing).

It’s a familiar story. Promise improved quality and lowered costs for CMS. Fail to achieve those goals (despite claims of success). Game the system to boost capitation payments and avoid meaningful oversight. These revelations aren’t news, indeed are noted regularly in HJM. Yet on and on it goes. CMS – the regulator asleep at the wheel – declined to testify (they can do that?).

The article by Jacobson & Blumenthal is more arcane – about how the traditional fully public fee-for-service part of Medicare has provided consistent national data on medical claims to help improve care and simple methods to adjust payments to support rural areas and medical education. They want CMS to somehow achieve the same abilities with Medicare Advantage, despite the variation and opacity implicit with a multitude of private insurance plans. There’s no indication it can ever happen.

Unfortunately, now traditional Medicare is pursuing a Medicare Advantage look-alike strategy. Engineered by CMS via the REACH program, for-profit ACO “entities” receive a capitated amount per patient. It will yield the same dynamics and vulnerabilities as Medicare Advantage. HJM has written often on this. CMS is catering to corporate interests.

In sum: myriad severe limitations associated with growing privatization of Medicare. There seems to be an implication around here somewhere … oh, I see it. Why don’t we transform Medicare into a fully public system, with no role for profit-seeking intermediaries, like it used to be? While we’re at it, let’s adopt the system universally, replacing private insurance, Medicaid, etc. Just like dozens of other countries. We could call it a “single payer.”

http://healthjusticemonitor.org…

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More Than 1,000 Ohio Docs Form Abortion Rights Group

"Physicians can mobilize," organizer says

By Jennifer Henderson
MedPage Today July 8, 2022

Marcela Azevedo, MD, sat in frustration late last month as she first watched the Supreme Court overturn Roe v. Wade, and then Ohio enact its 6-week “heartbeat” abortion ban.

Azevedo, a pulmonologist and critical care physician in Cleveland, told MedPage Today how she was gravely concerned about the life-threatening ramifications the decisions would have, and what it would mean for women to lose autonomy over their own bodies.

She was hardly alone.

After connecting with fellow Ohio physician Lauren Beene, MD, a pediatrician, and organizing on Facebook, Azevedo and Beene co-founded a grassroots group called Ohio Physicians for Reproductive Rights. The group decided to write and publish a letter detailing physicians’ anguish and medical opinions about what has happened, and what they believe a ban on abortions will do to their patients.

In 3 days, 700 physicians from all over the state and with countless specialties had signed the letter, Azevedo said. And in 5 days, 1,000 physicians had inked their name in approval. Since the letter’s publishing, there are now some 1,200 physicians who have joined the group, and that number is expected to grow.

“People’s lives are at stake when they don’t have access to abortion,” Azevedo said.

Pregnancy can be debilitating, depending on a person’s underlying conditions or complications that may arise, she said, adding that her group’s letter also includes strong language about what it means to lose autonomy over one’s own body.

“That changes the citizen status of a person, and that’s really impactful,” Azevedo said. “That’s emotionally overwhelming for me.”

“We are all extremely worried about the mental health of our patients,” she added.

Azevedo said that physicians have already witnessed parents requesting to place their adolescent children on birth control due to fear over Ohio’s law.

Physicians regularly prescribe birth control, she noted. However, the fact that people are electing to medicate themselves out of fear rather than necessity completely changes the tone of what patients are experiencing.

Additionally, the medical community has even reported difficulty obtaining certain medications that carry teratogenic risks for the treatment of patients with health conditions unrelated to pregnancy, due to concerns about what may be deemed criminal, she said.

“There are repercussions that affect pregnant and non-pregnant patients of all ages,” Azevedo said.

Azevedo and other members of Ohio Physicians for Reproductive Rights focus on those and other issues in their public letter addressed to patients.

“The decision to perform an abortion should be left solely to a woman and her physician,” the physicians further wrote. “Doctors are guided by evidence-based medicine and are bound by our commitment to do no harm. The ‘heartbeat bill’ is an intrusion of government on personal autonomy and will directly lead to oppression, illness, and death of countless women.”

The physicians added that Ohio’s law “will disproportionately affect women of color and individuals without the financial means to seek other options and will perpetuate the cycle of poverty.”

Ultimately, Azevedo said, Ohio Physicians for Reproductive Rights has both long- and short-term goals.

“Ideally, we get abortion on the ballot and codify abortion in the state of Ohio,” Azevedo said.

At the same time, “We need to help patients today,” she added.

The group would like to serve as a source of accurate information for patients and other healthcare professionals on the state of legal abortion in Ohio and on abortion more broadly. Another goal is to create a large network of providers that can quickly and safely help patients.

“I’m proud of the work that we did in just a couple of days,” Azevedo said. “Physicians can mobilize.”

She said that the Ohio-based group has been in touch with others in Indiana and Illinois.

“Physicians in every state where abortion has been banned or is now restricted can be doing the same thing,” Azevedo said.

https://www.medpagetoday.com…

Private Care Outsourcing in the UK Increases Mortality

Summary: An important study in the United Kingdom finds that care contracting with for-profit companies sharply raises preventable mortality. Privatization with for-profit providers threatens health outcomes in the UK and, as we have argued before, in the US.

Outsourcing health-care services to the private sector and treatable mortality rates in England, 2013–20: an observational study of NHS privatisation, The Lancet Public Health July 1, 2022, by Benjamin Goodair and Aaron Reeves

Summary:

Background: The effects of outsourcing health services to for-profit providers are contested, with some arguing that introducing such providers will improve performance through additional competition while others worry that this will lead to cost cutting and poorer outcomes for patients. We aimed to examine this debate by empirically evaluating the impact of outsourced spending to private providers, following the 2012 Health and Social Care Act, on treatable mortality rates and the quality of health-care services in England.

Methods: For this observational study, we used a novel database composed of … procurement contracts between April 1, 2013, and Feb 29, 2020 (n=645 674…), across 173 clinical commissioning groups (CCGs; regional health boards) in England … identifying [providers] as National Health Service (NHS) organisations, for-profit companies, or charities. We supplemented these data with rates of local mortality from causes that should be treatable by medical intervention, indicating the quality of health-care services. …

Findings: We found that an annual increase of one percentage point of outsourcing to the private for-profit sector corresponded with an annual increase in treatable [preventable] mortality of 0·38% (95% CI 0·22–0·55; p=0·0016) or 0·29 (95% CI 0·09–0·49; p=0·0041) deaths per 100 000 population in the following year. This finding was robust to matching on background characteristics, adjusting for possible confounding factors, and measurement error in our dataset. Changes to for-profit outsourcing since 2014 were associated with an additional 557 (95% CI 153–961) treatable deaths across the 173 CCGs.

Interpretation: The privatisation of the NHS in England, through the outsourcing of services to for-profit companies, consistently increased in 2013–20. Private sector outsourcing corresponded with significantly increased rates of treatable mortality, potentially as a result of a decline in the quality of health-care services.

Comment:

By Don McCanne, M.D.

Recently the founders of Physicians for a National Health Program and colleagues (including me) published an article in The Nation indicating why single payer Medicare for All is not enough and community ownership of the delivery system should be involved as well – a system like the British National Health Service. See our HJM post about that here.

In the meantime, our British friends have been experimenting with the alleged benefits of for-profit competition in health care, much as is promoted by the privatizers in our country – here privatizing both the delivery system and the payment/insurance system. Although we had plenty of data to show them the adverse consequences, nevertheless they proceeded with their studies and showed that their outsourcing of services to the private, for-profit sector significantly increased the rates of treatable mortality. Their experiment with privatizing health care killed patients.

(On a personal note, please excuse my repetition of a theme I have covered before. Having recently been exposed to a series of grand mal seizures which left me in a comatose state, I was placed in “hospice at home.” But fortunately having eventually partially recovered again, I felt like I had to take this opportunity to pound home once more real reform instead of being contented with incrementalism that takes such good care of private equity in health care but leaves millions of patients in need poorly served or not served at all. I know I won’t be around to see the reform we need, but maybe some of you will have your passion drive turned up to the level that we can get the job done. I know I can’t quit, so don’t you either.)

http://healthjusticemonitor.org…

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