PNHP

Single-payer amendment falls short in Mass. Senate

Single-payer amendment falls short in Mass. Senate

By GateHouse News Service
The Times and Courier (Clinton, Mass.), May 15, 2012

BOSTON — Several senators made a concerted push on Tuesday to put Massachusetts on a track toward single-payer health care, and though their plan failed it generated a level of debate on the topic unseen in recent years.

The Senate voted 15-22 against studying whether a single-payer, government model of health care could be more effective in reducing costs, but not before a bevy of Democratic lawmakers made the case that it would be a mistake to ignore a possible opportunity to make health care more affordable.

Rather than try to supplant the cost-control bill before the Senate with a proposal for a single-payer system, Sen. Jamie Eldridge filed an amendment that would seek to benchmark a single-payer system against the current model.

Though Eldridge said he believes single payer is the best way to reduce costs, he said his amendment allowed for the possibility that that may not be the case.

Sens. Sonia Chang-Diaz, Daniel Wolf, Marc Pacheco, William Brownsberger, Patricia Jehlen and Mark Montigby spoke at length in favor of Eldridge’s amendment, which would enable Massachusetts to follow a path being trod by Vermont and transition to a single payer universal health care system in 2015 if certain benchmarks are met.

Under the plan, implementation of a single payer system would be triggered in Massachusetts only if a state Institute of Health Care Finance and Policy determined at the start of fiscal 2015 that a single payer health care benchmark has outperformed the proposed cost growth benchmark included in cost containment legislation.

Brownsberger called the amendment “entirely consistent” with the thrust of the underlying bill that aims to shave $150 billion in health care costs over 15 years. Pacheco suggested the amendment represented a warning to the industry that he said has failed to control its costs by showing them that lawmakers were serious about alternatives.

Sen. Stephen Brewer, the Senate chair of Ways and Means, however, said he was “very nervous” by what the amendment proposed to do, warning that it could jeopardize an industry vital to employment in Massachusetts, and cast aside years of work aimed at reforming the private model. He noted that 84-year-olds from Canada come to Massachusetts for health care, rather than use the single-payer system in that country.

Sen. Richard Moore, the Senate co-chair of the Health Care Financing Committee, also panned the idea, predicting that most doctors would not work for the reimbursements he anticipated under a single payer system.

“There will be no cost control,” said Moore, warning of an “endless spiral of increasing costs.” Moore concluded, “It sounds great on paper but it isn’t realistic.”

But Moore left the door open a crack to return to this debate. After suggesting that Vermont will be unsuccessful in its efforts to control costs because older people from New York and New Hampshire will move to the Green Mountain state to take advantage of the system, he said if it does work it might be time then to revisit the subject.

 Sen. Daniel Wolf, a Harwich Democrat and owner of Cape Air, suggested the proposal was a “pro-business” initiative, calling it worthwhile to look into single-payer as an option if it held the promise of reducing premiums for employers and families.

And Chang-Diaz called the bill “humble” because it did not pretend to know whether single-payer was an affordable and viable option. “Even though I think the evidence is that single-payer is our best bet, this amendment does not presuppose that’s right,” she said.

Chang-Diaz called it “foolish and stubborn” to refuse to study the possibilities, drawing on her recent trip to Florida for her father’s induction into the astronaut hall of fame for inspiration about what’s possible.

Though Montigny described himself as “skeptical” that single-payer would work on the state level, he lamented that the status quo has also failed and that special interests are too powerful to allow for a serious debate about alternatives.

“The first thing we have to do is admit right now in this climate the employer can’t pay their premiums and the insured cannot,” Montigny said.

Eldridge’s amendment drew support from more than a third of the 39 members of the Senate, with supportive votes coming from Sens. Brownsberger (D-Belmont), Chang-Diaz (D-Boston), Katherine Clark (D-Melrose), Cynthia Creem (D-Newton), Sal DiDomenico (D-Everett), Kenneth Donnelly (D-Arlington), Benjamin Downing (D-Pittsfield), Eldridge (D-Acton), Susan Fargo (D-Lincoln), Jehlen (D-Somerville), Thomas McGee (D-Lynn), Montigny (D-New Bedford), Pacheco (D-Taunton), Stanley Rosenberg (D-Amherst), and Wolf (D-Harwich).

http://www.wickedlocal.com/clinton/news/x2047353473/Single-payer-amendment-falls-short-in-Senate#ixzz1v2sZwW6e

Private equity investors moving into dentistry

Dental Abuse Seen Driven by Private Equity Investments

By Sydney P. Freedberg
Bloomberg, May 16, 2012
Isaac Gagnon stepped off the school bus sobbing last October and opened his mouth to show his mother where it hurt. She saw steel crowns on two of the 4-year-old’s back teeth.
“The dentist man got me,” Gagnon remembers her son saying.
Isaac’s dentist was dispatched to his school by ReachOut Healthcare America, a dental management services company that’s in the portfolio of Morgan Stanley Private Equity, operates in 22 states and has dealt with 1.5 million patients. Management companies are at the center of a U.S. Senate inquiry, and audits, investigations and civil actions in six states over allegations of unnecessary procedures, low-quality treatment and the unlicensed practice of dentistry.
ReachOut is one of at least 25 dental management-services companies bought or backed by private-equity firms in the last decade. Dentists contract with the companies for marketing, scheduling, staff recruitment, supplies and other services. The companies account for about 12,000, or 8 percent, of U.S. dentists, according to Thomas A. Climo, a Las Vegas dental consultant.
Some of them have been riding a boom in Medicaid outlays on dentistry, which rose 63 percent to $7.4 billion between 2007 and 2010, outstripping the 4.9 percent growth in other dental spending. ReachOut and several of its private equity-backed rivals seek patients like Isaac Gagnon, who are covered by Medicaid, the federal-state insurance program for the poor and disabled.
On May 2, All Smiles Dental Center Inc., a management company owned by Chicago-based Valor Equity Partners, filed for bankruptcy protection. Its hand was forced in part by a Texas Medicaid action cutting off payment to some of its clinics because of allegedly “excessive” and “inappropriate” orthodontic care, according to an All Smiles executive’s affidavit included in the filing. All Smiles was part of a state audit in which 90 percent of Medicaid claims for orthodontic braces were found to be invalid because they weren’t medically needed, according to Christine Ellis, one of the auditors.
The All Smiles collapse followed another bankruptcy filing in February by Nashville-based Church Street Health Management LLC, which cited the costs of defending itself against lawsuits and investigations. Church Street is owned by Arcapita Inc., Carlyle Group LP (CG) and other private equity firms and affiliated with the Small Smiles network of dental clinics.
Dentistry is a fragmented, “cottage” industry ripe for management services, said Robert Fontana, chief executive officer of Aspen Dental Management, owned by Leonard Green & Partners, a Los Angeles private equity concern.
Management companies have “moved from being vendors of services,” such as patient billing, “into increasingly complex arrangements under which some — not all — have embedded themselves deeply into every aspect of the dental practice,” said Ken Burgess, an attorney for the North Carolina dental board.
http://www.bloomberg.com/news/2012-05-17/dental-abuse-seen-driven-by-private-equity-investments.html

Although Isaac reported to his mother, “The dentist man got me,” we should be concerned not only about the fate of Isaac and patients like him, but also about the fate of professionalism in dentistry and the fate of our tax dollars in this government-financed Medicaid program, now that private equity firms are moving “into increasingly complex arrangements under which some have embedded themselves deeply into every aspect of the dental practice.”
This fairly long Bloomberg article (link above) provides many more details that should make us question the wisdom of passively allowing private equity firms to take control, when their mission is profit, and low-income children with dental problems are merely their means to profit.
Dentistry is not alone here. We are seeing a massive transfer of Medicaid patients, including dual-eligibles, from traditional fee-for-service physicians to managed care organizations. States are shifting from an emphasis on trying to obtain decent care for these low-income patients, to an emphasis on trying to control the Medicaid component of the state budgets.
The managed care organizations continue to promise higher quality at lower costs, though the historical record is certainly not particularly supportive of these alleged outcomes. Patient advocates have expressed concern about the disruption in care and questionable access to future care, especially for specialized services. State authorities seem to be ignoring access and quality issues and focusing on spending, as they move forward with a let’s-try-this-and-we’ll-see-if-it-works attitude, and if it doesn’t, at least we’ve saved money.
A well designed single payer system would eliminate Medicaid – an underfunded program tainted with a welfare mentality – and would include everyone in a comprehensive program which would cover all appropriate dental services.
Under such a program Isaac would not have had to suffer torture and indignity “while several adults held him on the dental table,” as he received an “excessive” number of x-rays and “unnecessary” root canals. He would have been treated like any other child would be in an uptown dental practice, even if in a downtown clinic.
We can do this.

Family health costs now over $20,000 (MMI)

2012 Milliman Medical Index

Milliman Research Report
May 2012

The annual Milliman Medical Index (MMI) measures the total cost of healthcare for a typical family of four covered by a preferred provider plan (PPO). The 2012 MMI cost is $20,728, an increase of $1,335, or 6.9% over 2011. This is the first year the average cost of healthcare for the typical American family of four has surpassed $20,000.

Of the $20,728 medical cost for a family of four, the employer pays about $12,144 in employer subsidy while the employee pays the remaining $8,584, consisting of $5,114 in employee contributions and $3,470 in employee out-of-pocket costs.

Out-of-pocket costs are of particular significance given PPACA’s focus on actuarial value, a concept predicated on the percentage of a plan’s costs that is paid out of pocket by the insured. Figure 8 (link below) indicates how, as was the case last year, the MMI’s plan remains slightly better than a gold plan as defined by PPACA. The MMI plan has maintained a relatively stable actuarial value over time because employers typically adjust their plan designs on an annual basis to keep pace with increases in the underlying medical trend. If no such adjustments were made and deductibles and copays remained static, the plan would become richer and would eventually exceed the platinum threshold.

In addition to a typical PPO plan, many employers are providing employees an option that includes higher out-of-pocket cost sharing in exchange for employer contributions to a health savings account and lower payroll deductions. Along these lines, some plans that may become available through the state insurance exchanges may contain lower actuarial values than the type of plan exemplified by the MMI.

In the past year, the MMI plan did not undergo significant design changes. Long-term, employers may be looking for new design concepts that tackle the ongoing cost-control challenge. Design concepts under consideration may include a possible move toward increased use of defined contribution concepts and continued momentum toward high-deductible plans or plans leveraging accountable care organizations (ACOs).

Impact on MMI Family of Four

While several aspects of healthcare reform would have meaningful impact on the cost of insurance coverage, the effect on the total cost of care is very limited for our family of four. For example, medical loss ratio rules and stringent review of health insurance increases may reduce insurer profits and also put pressure on insurers to be as efficient and low-cost as possible. But the cost of care for this family of four is still $20,728, which excludes insurer profits and administrative expenses.

While efforts to be more administratively efficient may lead to lower premiums, they do not directly affect the cost of delivering healthcare to the MMI family of four.

http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf

Comment: 

By Don McCanne, MD

The 2012 Milliman Medical Index (MMI) shows that the average cost of health care for a family of four is now over $20,000 – actually pushing $21,000 ($20,728).

The MMI measures the average spending on health care for a family of four that is insured through an employer-sponsored PPO plan. It does not include the administrative costs or profits of the insurers nor the administrative costs of the employers to manage their health benefit programs. It includes only what is actually spent on health care.

Keep in mind that this represents spending on a relatively healthy component of our society – the healthy workforce and their young healthy families. It does not include those unable to work because of chronic disabilities, nor older, retired individuals who generally have greater health care needs. Thus if you pool everyone together in a universal risk pool, it can be anticipated that average costs would be even higher.

Median household income in 2010 was $49,445. This is not a family unit that is identical to an individual and his family of four with employer-sponsored insurance. Also this does not include the employer’s contribution to the health insurance premium which most economists consider to be paid by foregone wage increases. Nevertheless, it does provide a rough perspective showing that health care costs are placing an unbearable strain on household budgets.

Current proposals are aimed at reducing the financial burden on employers, but, as this report indicates, actual health care costs are not reduced by these measures. Thus the financial burden is being shifted more to workers and their families. Since these plans are, on average, slightly better than the gold plans in the exchanges (80 percent medical loss ratio) and most participants in the exchanges will have lower-valued bronze or silver plans, the burden will be even greater for those in the PPACA state exchanges.

We desperately need a more efficient and more equitable health care financing system. It is only as far away as the enactment of an improved Medicare for all.

Medical students embrace Medicare for all

By Ed Weisbart, M.D.
St. Louis Post-Dispatch, May 16, 2012

If you ever want to rekindle your hope for American medicine, spend time with medical students. These bright, energetic minds are going into medicine for all the right reasons — to help people, relieve suffering and find new ways to cure illness and eradicate disease.

Their idealism is a pleasure to behold, particularly to a veteran physician like me. Yet I’m painfully aware of how our current health care “system” can undermine students’ idealism, especially if they see no alternative.

Fortunately, a better alternative is waiting in the wings: a single-payer, improved Medicare-for-all program. Most Americans, including 59 percent of physicians, want access to an improved Medicare. I’m pleased to report that our physicians-in-training are strong supporters of this truly universal, comprehensive and affordable alternative.

Why? Even before they graduate, today’s medical students learn how our Byzantine, antiquated system of patchwork private insurance undermines medical care. They recognize an imperative to correct social injustice, for both moral and pragmatic reasons.

Medical students learn that as practicing doctors they’ll be dealing with dozens of different insurance schemes, each with its own rules, paperwork and bureaucratic headaches.

As physicians-in-training, they encounter patients who have delayed surgery until they qualified for Medicare at age 65 — often with more difficult and sometimes fatal complications as a result. They meet grandmothers who have had to decide between paying for medications for their hypertension and paying the rent.

They see patients with employer-sponsored health insurance get sick, lose their job, lose their insurance and declare bankruptcy. In fact, medical expenses are the most common cause of bankruptcy.

Like everyone else, medical students are shocked when they see these inequities and inefficiencies. They believe your wealth should not determine your health and that poor health should not be able to destroy your wealth. And, of course, they’re right.

I recently had a chance to discuss these issues with students at both of the major medical schools in town. Just last month the new St. Louis chapter of Physicians for a National Health Program brought in Dr. Garrett Adams, PNHP’s national president, and Dr. Carol Paris, a single-payer advocate from Maryland, to speak with students at those schools.

The sessions were co-sponsored by the American Medical Student Association, a long-standing supporter of a single-payer system that has about 30,000 members nationwide.

It was clear from our local meetings that growing numbers of our medical students reject our dysfunctional, insurance-based system. They want something better. Many understand there is a breathtakingly simple solution: fix the limitations in Medicare and provide it to every American. More than 30 percent of the health care dollar today is wasted on the administrative costs associated with the private health insurance industry; Medicare spent only 1.5 percent on administrative costs during 2011.

A landmark study in the New England Journal of Medicine (2003) showed that by replacing our fragmented, inefficient patchwork of multiple insurers with a single, streamlined, nonprofit agency like Medicare that pays all medical bills, our nation would save about $400 billion annually in reduced administrative costs — enough money to provide comprehensive, high-quality coverage to every American for no more than our nation spends now.

According to Gerald Friedman, professor of economics at the University of Massachusetts-Amherst in the March/April 2012 issue of Dollars and Sense, “a single-payer system would save as much as $570 billion now wasted on administrative overhead and monopoly profits.” Spending would increase by $326 billion from expanding coverage and adjusting Medicaid rates. Americans would net a savings of $244 billion, enjoy universal coverage and eliminate the dreadful scenarios described above. Disposable income would increase for 95 percent of Americans.

Because a single-payer system would possess enormous bargaining clout, it also would be able to rein in costs for pharmaceutical drugs and other medical supplies over the long haul.

I believe that adopting an “improved and expanded Medicare for all” is the best way for students and physicians to return to their mission of caring for our patients, rather than squandering our time navigating administrative barriers erected by insurance companies. And make no mistake — these are barriers to care, with dire consequences.

Although we spend more on health care per capita than any other country in the world, American life expectancy ranks 38th.

My colleagues and I came away from our student meetings confident that the future of medicine is in good hands. The medical students we met didn’t get lost in jaded political quagmires.

They know it’s inevitable. They just want it to happen now.

Me too.

Dr. Ed Weisbart is chairman of Physicians for a National Health Program—St. Louis.

http://www.stltoday.com/news/opinion/guest-commentary-medical-students-embrace-medicare-for-all/article_dc5f1135-4169-599b-b0c1-eeeb244bd9eb.html#ixzz1v2cuXkrg

Activists plan to protest WellPoint political giving at meeting

By J.K. Wall
Indianapolis Business Journal, May 15, 2012

A mix of union groups, activist investors and single-payer advocates plan to harangue WellPoint Inc.’s directors Wednesday during and after the company’s annual shareholders meeting.

The groups claim that the Indianapolis-based health insurer has used its corporate funds secretly to finance public policy positions they don’t like, such as the 2011 rollback of collective bargaining rights for public employees in Indiana, Ohio and Wisconsin, as well as advertisements opposing the health care reform law as it was being debated in 2009.

Activists are calling for increased disclosure from WellPoint, and some investment funds have promised to vote against WellPoint board members who they say have failed to exercise proper oversight of WellPoint’s political spending.

“Health care dollars should be spent on patients, not political campaigns,” said Dr. Rob Stone, a Bloomington emergency physician who will present the shareholder resolution for greater disclosure during the annual meeting.

Stone, an advocate of having the U.S. government insure all Americans, has presented a variety of resolutions at WellPoint annual meetings for the past five years. Dr. Quentin Young, the national coordinator for Physicians for National Health Care, will help Stone present the resolution.

As Stone and Young speak, a variety of protestors will be outside the Hilton hotel in downtown Indianapolis, chanting criticisms of WellPoint. The protest is being organized by union-related groups Health Care for America Now, The 99% Power Campaign, Central Indiana Jobs with Justice and the Indiana AFL-CIO.

The shareholder proposal, advanced initially by California-based Harrington Investments Inc., is unlikely to pass. A similar proposal put forth at WellPoint’s annual shareholders meeting two years ago was voted down by 82 percent of the company’s shareholders.

And the proposal does not have the backing of key corporate governance groups, such as ISS and Glass Lewis.

WellPoint spokesman Tony Felts noted that the company already publishes an annual report titled “Political Contributions and Related Activity Report.”

“Some of this reporting … goes above and beyond what others in our industry disclose,” Felts said. “We take positions, and make political contributions, solely on health care and health insurance-related issues. With over 70 years of experience in the health benefits field, we have good ideas to contribute to the discussion of improving the nation’s health care delivery system. Furthermore, we have a responsibility to our customers to remain engaged in health care policy discussions.”

However, Stone noted, WellPoint’s report does not include details on its contributions in 2009 to a television advertising campaign launched by the U.S. Chamber of Commerce against the health care reform bill. That campaign was funded in part by an $86 million contribution from America’s Health Insurance Plans, of which WellPoint is a member.

The secret campaign was revealed in a 2009 report from Bloomberg News.

“WellPoint has been kind of coy about answering questions about it, so we’re going to ask more questions at the meeting,” Stone said. He added, “If WellPoint is going to have a part in the long run, I think they need to be open and honest and cooperative, and work in a more straightforward way with the government regulations.”

Family health costs now over $20,000 (MMI)

2012 Milliman Medical Index

Milliman Research Report
May 2012
The annual Milliman Medical Index (MMI) measures the total cost of healthcare for a typical family of four covered by a preferred provider plan (PPO). The 2012 MMI cost is $20,728, an increase of $1,335, or 6.9% over 2011. This is the first year the average cost of healthcare for the typical American family of four has surpassed $20,000.
Of the $20,728 medical cost for a family of four, the employer pays about $12,144 in employer subsidy while the employee pays the remaining $8,584, consisting of $5,114 in employee contributions and $3,470 in employee out-of-pocket costs.
Out-of-pocket costs are of particular significance given PPACA’s focus on actuarial value, a concept predicated on the percentage of a plan’s costs that is paid out of pocket by the insured. Figure 8 (link below) indicates how, as was the case last year, the MMI’s plan remains slightly better than a gold plan as defined by PPACA. The MMI plan has maintained a relatively stable actuarial value over time because employers typically adjust their plan designs on an annual basis to keep pace with increases in the underlying medical trend. If no such adjustments were made and deductibles and copays remained static, the plan would become richer and would eventually exceed the platinum threshold.
In addition to a typical PPO plan, many employers are providing employees an option that includes higher out-of-pocket cost sharing in exchange for employer contributions to a health savings account and lower payroll deductions. Along these lines, some plans that may become available through the state insurance exchanges may contain lower actuarial values than the type of plan exemplified by the MMI.
In the past year, the MMI plan did not undergo significant design changes. Long-term, employers may be looking for new design concepts that tackle the ongoing cost-control challenge. Design concepts under consideration may include a possible move toward increased use of defined contribution concepts and continued momentum toward high-deductible plans or plans leveraging accountable care organizations (ACOs).
Impact on MMI Family of Four
While several aspects of healthcare reform would have meaningful impact on the cost of insurance coverage, the effect on the total cost of care is very limited for our family of four. For example, medical loss ratio rules and stringent review of health insurance increases may reduce insurer profits and also put pressure on insurers to be as efficient and low-cost as possible. But the cost of care for this family of four is still $20,728, which excludes insurer profits and administrative expenses.
While efforts to be more administratively efficient may lead to lower premiums, they do not directly affect the cost of delivering healthcare to the MMI family of four.
http://publications.milliman.com/periodicals/mmi/pdfs/milliman-medical-index-2012.pdf

The 2012 Milliman Medical Index (MMI) shows that the average cost of health care for a family of four is now over $20,000 – actually pushing $21,000 ($20,728).
The MMI measures the average spending on health care for a family of four that is insured through an employer-sponsored PPO plan. It does not include the administrative costs or profits of the insurers nor the administrative costs of the employers to manage their health benefit programs. It includes only what is actually spent on health care.
Keep in mind that this represents spending on a relatively healthy component of our society – the healthy workforce and their young healthy families. It does not include those unable to work because of chronic disabilities, nor older, retired individuals who generally have greater health care needs. Thus if you pool everyone together in a universal risk pool, it can be anticipated that average costs would be even higher.
Median household income in 2010 was $49,445. This is not a family unit that is identical to an individual and his family of four with employer-sponsored insurance. Also this does not include the employer’s contribution to the health insurance premium which most economists consider to be paid by foregone wage increases. Nevertheless, it does provide a rough perspective showing that health care costs are placing an unbearable strain on household budgets.
Current proposals are aimed at reducing the financial burden on employers, but, as this report indicates, actual health care costs are not reduced by these measures. Thus the financial burden is being shifted more to workers and their families. Since these plans are, on average, slightly better than the gold plans in the exchanges (80 percent medical loss ratio) and most participants in the exchanges will have lower-valued bronze or silver plans, the burden will be even greater for those in the PPACA state exchanges.
We desperately need a more efficient and more equitable health care financing system. It is only as far away as the enactment of an improved Medicare for all.

Should nurses assume the role of family physicians?

Education Gaps between Family Physicians and Licensed Nurse Practitioners

From the Association of Family Medicine Residency Directors
Annals of Family Medicine, May/June 2012

As millions of Americans gain coverage for medical care in the coming years and as the need for primary care in patient-centered medical home (PCMH) models increases, our medical homes will need to provide more access to care. One such method is through advanced physician extenders which include physician assistants and nurse practitioners. Many entities are talking about allowing Advanced Registered Nurse Practitioners (ARNPs) work more independently without physician involvement. However, the vast difference in clinical training between family physicians and ARNPs is significant. Also, an effective provider in a PCMH is expected to manage without consultation a broad spectrum of disease. Therefore, practices without physician counterparts could lead to a tier of primary care that is limited in its effectiveness. ARNPs are a tremendous asset in providing some primary care services, ideally partnered with physicians in group settings, but have significant limitations when independently evaluating and managing undifferentiated patients due to the superficial coverage of medical topics during their training. The skill sets are complementary to each other, but not equal.

ARNP schools exhibit a wide variation of training standards from school to school and from state to state. There is no national accreditation body like the Accreditation Counsel for Graduate Medical Education (ACGME) that monitors advanced nursing profession schools or creates national standards for clinical experiences. Without a similar structure to the ACGME, it is impossible to assess the quality of the education across these various schools.

The diagnostic challenges primary care physicians face on a daily basis require they have extensive clinical exposure in order to perform efficiently. The depth of knowledge required to filter undifferentiated patients’ complaints and to understand the subtleties of management is vast. The average family medicine physician has 21,000 total hours of training, most of it with clear patient management responsibilities and decreasing levels of supervision. The total hours of training a nurse practitioner receives is 2,300 to 5,300 hours depending on the advanced nursing program, and much of the clinical training is observational. Many states only require a 30-day observation period of a licensed active physician before an ARNP can deliver care unsupervised. Grandfathering people into independent practice would be like grandfathering a family physician into a subspecialty after doing a month of observation in that specialty.

In the end, to practice independently, one should be judged by those who have the experience and background to make that assessment. Family physicians are the experts of primary care in this country and our understanding of what it takes to practice competently and independently is quite thorough. Family physician faculty that teach residents are skilled at making such assessments.

We believe there are excellent roles for physician extenders who work in collaborative settings with physicians, enabling more independence for the physician extenders. The medical team in the PCMH has key roles for Physician Assistants and ARNPs within its structure. Just as physicians gain greater skill with experience, these practitioners will gain great skill in many aspects of primary care as their experience develops over time. However, the underlying knowledge base and formative clinical experience cannot be shortcut. Not knowing what one doesn’t know can be dangerous to the public. On the physician side, we would never allow a 2nd- or 3rd-year medical student (who would have the equivalent amount of training as an ARNP), to evaluate and manage patients independently. Though states may pass laws that allow other providers with less training to practice independently, it doesn’t change the reality that without competent physician supervision, we are lowering the standard of acceptable primary care and creating a 2-tiered system of access for our community.

Todd Shaffer, MD, MBA, Michael Tuggy, MD, Stoney Abercrombie, MD, Sneha Chacko, MD, Joseph Gravel, MD, Karen Hall, MD, Grant Hoekzema, MD, Lisa Maxwell, MD, Michael Mazzone, MD and Martin Wieschhaus, MD

http://www.annfammed.org/content/10/3/270.full

And…

Broadening the Scope of Nursing Practice

By Julie A. Fairman, Ph.D., R.N., John W. Rowe, M.D., Susan Hassmiller, Ph.D., R.N., and Donna E. Shalala, Ph.D.
The New England Journal of Medicine, January 20, 2011

The critical factors limiting nurse practitioners’ capacity to practice to the full extent of their education, training, and competence are state-based regulatory barriers. States vary in terms of what they allow nurse practitioners to do, and this variance appears not to be correlated with performance on any measure of quality or safety. There are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care than those in less restrictive states or that the role of physicians in less restrictive states has changed or deteriorated.

Sixteen states plus the District of Columbia have already liberalized and standardized their scope-of-practice regulations and allow nurse practitioners to practice and prescribe independently.

This is a critical time to support an expanded, standardized scope of practice for nurses. Economic forces, demographics, the gap between supply and demand, and the promised expansion of care necessitate changes in primary care delivery. A growing shortage of primary care providers seems to ensure that nurses will ultimately be required to practice to their fullest capacity. Fighting the expansion of nurse practitioners’ scope of practice is no longer a defensible strategy. The challenge will be for all health care professionals to embrace these changes and come together to improve U.S. health care.

http://www.nejm.org/doi/full/10.1056/NEJMp1012121

Comment:

By Don McCanne, MD

Is there a difference between a nurse and a physician? More specifically, can advanced registered nurse practitioners replace family physicians in the independent practice of medicine? Or should they?

These are important questions. There is an urgent need to reinforce our primary care infrastructure. Should we do this by continuing to expand medical homes by including nurse practitioners as parts of teams led by primary care physicians? Or should we encourage the independent practice of nurse practitioners in competition with physician practices?

Since there is a shortage of family physicians, it seems that the proper solution would be to train more family physicians. Is it really logical to convert another category of health care professionals – nursing – into independent physicians?

Advanced nurse practitioners have much to contribute to the team comprising the medical home. But would it be proper for medical homes to be led by nurses while excluding physicians?

It’s really all about the patient. Medical teams should be designed foremost to serve the patient. It seems like there should be a physician in there somewhere.

Oregon Activists Look to Grassroots Approach to Win Universal Health Care

By Peter Shapiro
Labor Notes, May 14, 2012

With health care premiums rising three times faster than workers’ income, more and more unions have come to see the existing health care system as unsustainable, despite their best efforts at the bargaining table.

In Oregon, activists are responding by rejuvenating a dormant campaign to win a health care system that covers everyone — and pays for it by cutting out the insurance companies. The concept is called “single payer.”

This isn’t the first time that Oregon activists have tried to win single payer. Ten years ago, they put an initiative on the ballot, but despite initially promising polls, the measure was trounced — victim of a flood of insurance company money and the sharp opposition of the Oregon AFL-CIO, which called it a threat to union health plans.

Times have changed.

When Portland Jobs with Justice began making the rounds of local union halls in 2008, urging support for national single-payer legislation sponsored by Representative John Conyers, the response was generally sympathetic. The national AFL-CIO has endorsed single payer on principle, and current state President Tom Chamberlain has been a consistent supporter.

The current focus isn’t just gaining endorsements, however.

Three activists from the Vermont Workers Center toured Oregon in December at the invitation of local Jobs with Justice chapters to spread the word on how they won landmark legislation laying the groundwork for a single-payer health care system in their state.

Their essential message: take it to the grassroots. Don’t split hairs over policy analysis. Don’t try to win over legislators who have heard all the arguments but haven’t felt the heat from their constituents. Don’t even use technical terms like “single payer,” unless you’re talking to people who already know what it means.

Instead, talk about health care as a human right — something everybody should have, regardless of the state of their bank account or their immigration papers, their medical condition, their job, their age, race, or gender, or whether some insurance underwriter thinks they’re a “good risk.” Seek out the people in all walks of life who have been burned by the health care system, get their stories, and turn them into effective activists and advocates.

For three years Vermonters built support in every corner of the state through one-on-one surveys, photo petitions, and public meetings where politicians were invited to hear testimony, comparable to the Workers’ Rights Board hearings that are a standard part of the Jobs with Justice toolkit.

The Vermonters’ tour made a tremendous impact, from metropolitan Portland to rural communities in eastern Oregon. Not everyone agreed with every aspect of the VWC approach, but everyone was talking about it. By the end of January, a new statewide coalition had convened to “create a comprehensive, affordable, publicly funded, universal health care system serving everyone in Oregon and the United States.”

By April, the coalition had a name — Health Care for All-Oregon — and close to 50 affiliates, including several statewide unions, immigrant rights groups, and community organizations ranging from the Rural Organizing Project to Elders in Action to Sisters of the Road (which advocates for the homeless).

Some, like Physicians for a National Health Program (PNHP) and the Mad as Hell Doctors (whose cross-country tour in 2009 brought the message to a host of new audiences), make single payer their main focus. The majority of affiliates have other priorities, but have come to understand that the collapse of our health care system threatens everything else on their agenda.

The Oregon Latino Health Coalition, which has labored tirelessly under the radar to secure medical services for the state’s 150,000 undocumented, recognized immediately that the Health Care for All human rights framework provides an opportunity for open advocacy without being isolated or marginalized. In voting to affiliate, the Representative Assembly of the Oregon Education Association noted that the skyrocketing cost of teachers’ health benefits is draining money out of the classroom and has left the union increasingly vulnerable to attack.

State vs. National

For unions, perhaps the biggest sticking point has been the question of state vs. national legislation. When Congress passed the Affordable Care Act in spring 2010 and ended, for the time being, the prospect of any genuine national health care reform at the federal level, Portland Jobs with Justice made a strategic decision to pursue state legislation as a way to keep single payer before the public.

Working with state Representative Michael Dembrow (who is also a Teachers union officer and Jobs with Justice member), with activists from the 2002 initiative campaign, and with PNHP and the Mad as Hell Doctors, we drafted a bill that attracted a dozen legislative co-sponsors. In March 2011, supporters of the Dembrow bill staged a mass rally on the Capitol steps followed by a dramatic two-hour hearing before the House Health Care Committee. The legislation didn’t make it to the House floor, but it has more than proved its value as an organizing tool, energizing new activists across the state.

Some single-payer supporters question how far it can be implemented at the state level. They point to a host of federal laws and regulations that would need to be waived, and the difficulty of achieving the cost savings of a truly universal risk pool when the program stops at the state line.

This has in fact been a problem in Vermont, whose new law, while a giant step in the right direction, falls short of single payer. (Many Vermonters remain outside the risk pool, and funding, while administered by the state, still comes from multiple sources.) Unions with multi-employer Taft-Hartley health plans, which often cross state lines, worry that a statewide risk pool will not be viable enough to maintain the level of coverage they currently enjoy.

For this reason, Portland Jobs with Justice has made national legislation the ultimate objective, and has taken the position that the best union health plans set the standard by which any public plan should be assessed. Significantly, the “insurance exchange” provisions of the Affordable Care Act directly undermine Taft-Hartley trusts, by giving small employers a way to bypass unions and buy inferior, cut-rate insurance coverage for their workers. For unions, the Affordable Care Act is no solution: even if it
survives the current Supreme Court challenge, its lack of cost controls and other internal contradictions will render it unworkable.

The challenge for us is to be ready with an alternative that has popular support, and the more states join Vermont in projecting such alternatives, the better.

Health Care for All-Oregon wants to bring everyone together to hammer out a strategy that works for all. The immediate task in Oregon, though, is not legislation but building the kind of mass base that changes the political climate in the state and makes legislation possible.

Efforts to pass single-payer bills in Vermont go back 20 years, but it was only after the Vermont Workers Center did three years of organizing around the principle of health care as a human right that they got results. Now that the Oregon coalition is up and running, we’ll see how much of Vermont’s game plan can be successfully exported.

Peter Shapiro is an organizer with Portland Jobs with Justice.

PNHP note: Longtime single-payer activists in Vermont, including PNHP members, were instrumental in bringing business leaders on board, getting a world-renowned economist hired to complete a fiscal study of single payer, drafting legislation, and creating favorable political conditions for the bill’s passage. Single-payer activists also continue to monitor the bill to make sure it is on the right track — i.e. toward single payer (see www.vermontforsinglepayer.org).  In other words, while the “health care is a human right” strategy played a role, single-payer advocates contributed heavily to Vermont’s recent advances.

http://labornotes.org/2012/05/oregon-activists-look-grassroots-approach-win-universal-health-care

Single-payer health care: What could it do on the national stage?

By Bob Herman
Becker’s Hospital Review, May 14, 2012

One of the biggest buzz words in health care today is “reform” — and to quote REO Speedwagon, “It’s everywhere.” Perhaps the biggest poster child of the term “reform” is the Patient Protection and Affordable Care Act that President Barack Obama signed into law in March 2010.

Some argue the law — which is currently being contested in the Supreme Court —overreached its bounds in reforming what most would say is a broken health care system, but many others believe the law did not go far enough, especially when it comes to providing maximum health coverage and creating significant savings in the delivery system.

Enter, single payer.

Single-payer health care has made a lot of headlines in the past year, most notably in Vermont. In May 2011, Gov. Peter Shumlin signed the single-payer bill into law, which laid the groundwork for creating a publicly funded health system in which the state would act as the main insurer by 2017. Montana Gov. Brian Schweitzer also asked the federal government for a waiver this past September so Montana could set up its own single-payer health system based on what is used by its northern neighbor, Saskatchewan, although no waiver has been granted. Even California lawmakers proposed a bill in January that would have established a single-payer health care system, although it was ultimately defeated.

It’s vividly apparent that health care spending is out of control in the United States, considering it is at its highest level ever. According to the National Health Expenditure Accounts, total health expenditures reached $2.6 trillion in 2010, which translates to roughly $8,402 per person — a record high. A recent study from The Commonwealth Fund also found health care spending in the United States dwarfs a dozen other industrialized countries, but the varied quality measures do not make the U.S. health care system “notably superior.”

“The mistake the United States made is that we poured so much money into health care and we postponed our reforms for so long, we’ve created very powerful stakeholders,” said William Hsiao, PhD, professor of economics at the Harvard School of Public Health in a Harvard Crimson report last year. “They are so invested, they make it so difficult, if not impossible, to reform the system.”

Much of that money and investment is tied up in numerous insurers that many think complicate the system beyond control and create excessive administrative overheads — and these administrative costs are borne both by the health insurance sector as well as the provider sector. “The biggest issue in health care is the complexity of the various payment streams and arrangements,” says Jim Grigg, CPA, partner and national health care assurance practice leader at Crowe Horwath. “Health care reform didn’t go anywhere near far enough in terms of reforming the system. The number and types of contracts with any given insurer, between each hospital, different by state — it’s a morass of complications.”

So could a national single-payer system — a system that is very different from the current state of affairs and is also different from the PPACA — help hospitals and create a more beneficial health care system at large? Understanding what would occur in a single-payer system, as well as its challenges and benefits, could lead to a clearer answer.

The basic tenets behind a true single-payer system

A single-payer health care system is a structure that would replace the multiple payers and health insurers with one public or quasi-public agency that organizes the health financing — and only the health financing. Medical decisions would still be left up to patients and physicians. More likely than not, the federal government would act as the sole agency in reimbursing providers (similar to CMS now), or state governments could act as the single payer (like in Vermont, potentially). However, health care delivery systems, such as hospitals, can still be private, says Kip Sullivan, JD, steering committee member of the Minnesota chapter of Physicians for a National Health Program.

All citizens would have health insurance from the day they are born, and all medically necessary services — which include preventive care, mental health, reproductive health, dental, vision, prescription drug and most acute-care services — would be covered. While the PPACA expands health insurance to millions and places a larger emphasis on preventive care instead of “sick” care, the dominant financing mechanisms and intermediaries were not altered significantly.

As is the case with any proposal to make coverage universal, a central question of single-payer health care is: How will this be funded? Like many broad questions, there’s more than one possible answer. A single-payer system could be funded from numerous, smaller taxes (e.g., a tax on candy, a tax on ammunition, etc.), a single tax on one source (e.g., payroll or income) or a mix of two or three taxes, Mr. Sullivan says.

Another important factor of a single-payer system is the focus on clinical decisions rather than complicated payment streams, says James Burdick, MD, professor of surgery at the Johns Hopkins University of Medicine. Similar to the goals of the PPACA, a focus on the “Triple Aim” — improving the health of the population, enhancing the patient experience of care and reducing the per capita costs of care — starts with an unwavering foundation in clinical quality. “Evidence-based medicine should be maximized by this process,” Dr. Burdick says. “The things that would be controlling the costs are doing the right care instead of arbitrary administrative decisions.”

Vermont’s version of a single-payer system is still evolving and was based on the research of Dr. Hsiao, who is internationally renowned for his single-payer health care economics. Vermont’s Green Mountain Care Board, a five-person committee comprised of state health care professionals and other community members, is tasked with setting up the state’s system, and it will make a formal financing proposal in 2013. By the time the system is fully operating in 2017, it is projected to save the state roughly $880 million through savings in health premiums and other general health care costs.

The challenges and benefits of single-payer

Daniel Fass, MD, director of the Institute for Image-Guided RadioTherapy in Rye, N.Y., has long thought the U.S. health care system has needed massive reform. He says the PPACA was a good start but, like all legislation, will evolve over time. A single-payer system, however, runs into one of the biggest obstacles of any new government initiative: skepticism. “If single-payer were enacted, then the federal government would have even more control, and most people at this point in time don’t want to see that,” Dr. Fass says.

Because Vermont is a smaller state with fewer hospitals, a single-payer pilot is more manageable, he says. As the Green Mountain Care Board and Gov. Shumlin unveil their plans for complete state funding, its results will be influential if other states take the plunge and request a single-payer waiver. “If Vermont rolled out single-payer and succeeded in terms of cost control, then other states would look at it as a model going forward, but that doesn’t mean that’d be the best model for all states,” Dr. Fass says.

Tom Huebner, president and CEO of Rutland (Vt.) Regional Medical Center, says his hospital is already looking ahead to prepare for the single-payer changes. While the state law will expand insurance access to all Vermont residents — something he calls the most beneficial part of the law — the challenge of adequate physician volume looms.

“We will require a sufficient number of primary care and specialty physicians who are able and willing to participate,” Mr. Huebner says. “A lot of us are concerned that if compensation for ph
ysicians is not maintained at a level that is competitive with the rest of the country, we’ll see physicians leaving our state. We have a lot of people promising us that won’t happen, but that’s still a worry.”

In addition to the lack of legislative will and physician supply, Dr. Fass — who used to be the director of radiation oncology at Greenwich (Conn.) Hospital — says the enormous transition to a single-payer system will leave many in the for-profit health insurance industry scrambling for jobs, since for-profit insurers would be siphoned out.

However, as Mr. Sullivan points out, several former single-payer bills that were proposed at various government levels — such as U.S. House Bill 676 in 2007 and Minnesota’s Senate Bill 118 in 2009 — would provide a certain level of funding to retrain displaced health insurance workers into new health care roles during the first few years of single-payer implementation. “Also, when health insurance employees lose their jobs because of single-payer legislation, they will know they won’t also lose their health insurance, which is what happens to unemployed people under our current multiple-payer system,” Mr. Sullivan says.

When it comes to a single-payer health care system, two benefits immediately jump to the forefront: Everyone is insured, and administrative costs are greatly slashed. The “everyone is insured” benefit is pretty straightforward — uncompensated care for hospitals and other providers would be eliminated if everyone had health insurance, and providers would not have to worry about missed reimbursements and exorbitant spending to chase payments on the back end. The overall administrative cost savings, however, require deeper digging for true impact.

Hospitals, physicians and other health care providers are currently mired in an ecosystem with literally tens of thousands of ways to be paid. The number of different HMOs, PPOs and other managed care organizations and contracts is almost dizzying. At the heart of the issue is government payers (Medicare and Medicaid) versus private health insurers.

Robert Zirkelbach, press secretary of America’s Health Insurance Plans, the lobbying association for private health insurers, points to several reports — such as one that tested hospital readmission rates in Medicare Advantage versus traditional Medicare — on the effectiveness of private health plans. In the end, he says a single-payer system would be eliminating a vital cog of the U.S. health care machine

“Surveys consistently show that the vast majority of policyholders express strong satisfaction with their private health plans,” says Robert Zirkelbach, press secretary of America’s Health Insurance Plans, the lobbying association for private health insurers. “Health plans have pioneered programs to coordinate care for patients with chronic conditions, promote prevention and wellness and incentivize providers to improve the quality and safety of patient care. Data show that private plans outperform current government-run programs on a variety of quality and safety measures, including reducing hospital-acquired infections, never-events and preventable hospital readmissions.”

Michael Diamond, MD, of the Allergy, Asthma, Arthritis and Lung Center in Daytona Beach, Fla., also argues a single-payer system would expose physicians to “unwanted oversight” by the government in their health care decisions. “With the newfound power to benchmark physicians and regulate payments, the government will inevitably restrict the use of potentially beneficial therapies and pay differentially for perceived differences in quality, with potential unintended consequences such as increased health care disparities,” he wrote in an article for the American Journal of Respiratory and Critical Care Medicine.

However, several other studies have shown that the government programs — specifically Medicare, which is the basis of a single-payer system — surpass private health insurers in several of those areas and also save money.

According to a Kaiser Family Foundation (pdf) report, the administrative costs of Medicare have stayed incredibly low over the past several years — less than 2 percent of all Medicare expenditures. In fact, the most recent Medicare Trustees report found administrative expenses accounted for only 1.4 percent of total expenditures across Medicare Parts A, B and D. On the other hand, in a true apples-to-apples comparison, administrative costs of Medicare Advantage plans, the private Medicare insurers better known as Medicare Part C, account for approximately 11 percent of spending — or almost 8 percent more than traditional Medicare, according to Congressional Budget Office reports. Other private, commercial health plans have administrative costs stretching as high as 30 percent, on average. (The PPACA’s medical loss ratio currently caps private health insurer administrative costs at 20 percent in the small group and individual market.)

By virtue of having to deal with the plethora of private insurers, hospitals and physicians incur enormous overhead expenses as well. In fact, according to an article from the New England Journal of Medicine, the average U.S. hospital devotes 24.3 percent of spending to administration and billing. A study in the Annals of Family Medicine found that physicians devote almost a third of their day to simple documentation and paperwork alone. Ezekiel Emanuel, MD, a bioethicist at the National Institutes of Health, wrote in a recent New York Times article that the total U.S. billing and administrative costs equal roughly $360 billion per year, or 14 percent of total U.S. health care expenditures. Hospitals and physicians take up half of those costs because they have to perform the “myriad…administrative functions associated with health care,” said Dr. Emanuel.

A single-payer health care system would take on a traditional “Medicare-for-all” approach, thus leading to significantly lower administrative costs. Hospitals that are able to break even or profit on Medicare today would be in an even better position to succeed. “If hospitals and physicians don’t figure out that administrative waste is the primary problem and allow others to say overuse is the problem, then they are going to be micromanaged for as long as the myth lives,” says Mr. Sullivan of the Minnesota chapter of Physicians for a National Health Program.

Paul Spencer, CPC, CPC-H, compliance officer for Fi-Med Management, used to work in the private health care insurance industry. He says the high costs of the private health insurance industry are mirrored in other health care initiatives spearheaded by private enterprises. For example, CMS outsources its Medicare Recovery Auditor program to private contractors, who are tasked with recouping improper Medicare claims. Despite reports of large overpayment recoveries (RACs have reportedly collected $1.27 billion in overpayments since 2009), hospitals have successfully appealed more than 70 percent of their RAC denials that were initiated by the private RACs. “We have to get past the orthodoxy that the private sector can do it better than government,” Mr. Spencer says. “With the Medicare RAC program and the amounts of dollars chasing shadows, you would have a hard time convincing me the private sector is doing well.”

Dr. Burdick of Johns Hopkins agrees, saying the United States needs to stray away from commerce in medicine and focus on physician-led efforts to make the right clinical judgments that also lead to lower costs. “Because we would be defining what care is going to be given, we could get rid of any interference and massive administrative problems,” he says.

The universal health care coverage and reduced administrative costs of a single-payer system would eventually lead to one of the most important byproducts: heightened efforts to become a healthier population. “If you had a one-payer system, think how easy that would be to account for,” Mr. Grigg says. “Unfortunately, what happens i
s the amount of energy that goes into accounting for all these programs, payers, patient billing — those are all dollars that don’t go toward patients.

“Wouldn’t we rather have those dollars in the emergency department than in patient accounts?” he adds. “We have burdened our hospitals to have huge administrative overheads that aren’t doing a thing to promote health in this country.”

A future for single-payer?

If single-payer is to hold any weight in the United States, Vermont will be seen as the primary barometer over the next several years. “It will be interesting years from now when Vermont has had its health care system up and running to see how many businesses relocate to Vermont,” Mr. Spencer of Fi-Med Management says. “If you have the ability to get a large chunk of health care investment off your bottom line, it has to be tempting to move into that kind of environment.”

Jeff Fried, CEO of Beebe Medical Center in Lewes, Del., says he’s uncertain if single-payer should be the next path for the U.S. health care system, but it’s something that must be considered, if for nothing else to create a more seamless episode of care for patients. “One of the big problems is [the health care system] operates in silos,” Mr. Fried says. “Acute-care, outpatient, home care providers, long-term acute-care providers, insurers, doctors that are employed, doctors that are privately run. Communication is often times fragmented, and it’s a very complicated system.”

It’s clear legislation is pushing the fee-for-service model out of the health care playing field, but Mr. Fried says FFS is not the major contributor to higher health care costs. “One of the problems with the system is that everybody, hospitals included, has focused on expanding, growing and developing services,” Mr. Fried says. “Certainly they are necessary and needed, but sometimes in the course of that, we have lost track of how we put ourselves in a better position to take care of people who need access to health care.”

Single-payer health care is normally thought about in terms of foreign health care systems, but as costs continue to spiral out of control, the industry must start asking itself: Is the current path of reform enough? Or will “reform” just be another buzz word? “If we’re going to have a system based on insurance and spreading risk, it’s only fair to have everyone participate,” Mr. Fried says. “My own personal thoughts about the issues we’re struggling with are that we don’t seem to be very unified. Everyone is fighting for their own issues. In our society, health care is not a privilege. However, it should be something everyone has access to, and everyone should bear some responsibility.”

“Even if [the PPACA] were thrown out, we have to get out of our individual silos and work together to create a better system for everybody,” Mr. Fried adds.

http://www.beckershospitalreview.com/racs-/-icd-9-/-icd-10/single-payor-healthcare-what-could-it-do-on-the-national-stage.html

Should nurses assume the role of family physicians?

Education Gaps between Family Physicians and Licensed Nurse Practitioners

From the Association of Family Medicine Residency Directors
Annals of Family Medicine, May/June 2012
As millions of Americans gain coverage for medical care in the coming years and as the need for primary care in patient-centered medical home (PCMH) models increases, our medical homes will need to provide more access to care. One such method is through advanced physician extenders which include physician assistants and nurse practitioners. Many entities are talking about allowing Advanced Registered Nurse Practitioners (ARNPs) work more independently without physician involvement. However, the vast difference in clinical training between family physicians and ARNPs is significant. Also, an effective provider in a PCMH is expected to manage without consultation a broad spectrum of disease. Therefore, practices without physician counterparts could lead to a tier of primary care that is limited in its effectiveness. ARNPs are a tremendous asset in providing some primary care services, ideally partnered with physicians in group settings, but have significant limitations when independently evaluating and managing undifferentiated patients due to the superficial coverage of medical topics during their training. The skill sets are complementary to each other, but not equal.
ARNP schools exhibit a wide variation of training standards from school to school and from state to state. There is no national accreditation body like the Accreditation Counsel for Graduate Medical Education (ACGME) that monitors advanced nursing profession schools or creates national standards for clinical experiences. Without a similar structure to the ACGME, it is impossible to assess the quality of the education across these various schools.
The diagnostic challenges primary care physicians face on a daily basis require they have extensive clinical exposure in order to perform efficiently. The depth of knowledge required to filter undifferentiated patients’ complaints and to understand the subtleties of management is vast. The average family medicine physician has 21,000 total hours of training, most of it with clear patient management responsibilities and decreasing levels of supervision. The total hours of training a nurse practitioner receives is 2,300 to 5,300 hours depending on the advanced nursing program, and much of the clinical training is observational. Many states only require a 30-day observation period of a licensed active physician before an ARNP can deliver care unsupervised. Grandfathering people into independent practice would be like grandfathering a family physician into a subspecialty after doing a month of observation in that specialty.
In the end, to practice independently, one should be judged by those who have the experience and background to make that assessment. Family physicians are the experts of primary care in this country and our understanding of what it takes to practice competently and independently is quite thorough. Family physician faculty that teach residents are skilled at making such assessments.
We believe there are excellent roles for physician extenders who work in collaborative settings with physicians, enabling more independence for the physician extenders. The medical team in the PCMH has key roles for Physician Assistants and ARNPs within its structure. Just as physicians gain greater skill with experience, these practitioners will gain great skill in many aspects of primary care as their experience develops over time. However, the underlying knowledge base and formative clinical experience cannot be shortcut. Not knowing what one doesn’t know can be dangerous to the public. On the physician side, we would never allow a 2nd- or 3rd-year medical student (who would have the equivalent amount of training as an ARNP), to evaluate and manage patients independently. Though states may pass laws that allow other providers with less training to practice independently, it doesn’t change the reality that without competent physician supervision, we are lowering the standard of acceptable primary care and creating a 2-tiered system of access for our community.
Todd Shaffer, MD, MBA, Michael Tuggy, MD, Stoney Abercrombie, MD, Sneha Chacko, MD, Joseph Gravel, MD, Karen Hall, MD, Grant Hoekzema, MD, Lisa Maxwell, MD, Michael Mazzone, MD and Martin Wieschhaus, MD
http://www.annfammed.org/content/10/3/270.full

And…

Broadening the Scope of Nursing Practice

By Julie A. Fairman, Ph.D., R.N., John W. Rowe, M.D., Susan Hassmiller, Ph.D., R.N., and Donna E. Shalala, Ph.D.
The New England Journal of Medicine, January 20, 2011
The critical factors limiting nurse practitioners’ capacity to practice to the full extent of their education, training, and competence are state-based regulatory barriers. States vary in terms of what they allow nurse practitioners to do, and this variance appears not to be correlated with performance on any measure of quality or safety. There are no data to suggest that nurse practitioners in states that impose greater restrictions on their practice provide safer and better care than those in less restrictive states or that the role of physicians in less restrictive states has changed or deteriorated.
Sixteen states plus the District of Columbia have already liberalized and standardized their scope-of-practice regulations and allow nurse practitioners to practice and prescribe independently.
This is a critical time to support an expanded, standardized scope of practice for nurses. Economic forces, demographics, the gap between supply and demand, and the promised expansion of care necessitate changes in primary care delivery. A growing shortage of primary care providers seems to ensure that nurses will ultimately be required to practice to their fullest capacity. Fighting the expansion of nurse practitioners’ scope of practice is no longer a defensible strategy. The challenge will be for all health care professionals to embrace these changes and come together to improve U.S. health care.
http://www.nejm.org/doi/full/10.1056/NEJMp1012121

Is there a difference between a nurse and a physician? More specifically, can advanced registered nurse practitioners replace family physicians in the independent practice of medicine? Or should they?
These are important questions. There is an urgent need to reinforce our primary care infrastructure. Should we do this by continuing to expand medical homes by including nurse practitioners as parts of teams led by primary care physicians? Or should we encourage the independent practice of nurse practitioners in competition with physician practices?
Since there is a shortage of family physicians, it seems that the proper solution would be to train more family physicians. Is it really logical to convert another category of health care professionals – nursing – into independent physicians?
Advanced nurse practitioners have much to contribute to the team comprising the medical home. But would it be proper for medical homes to be led by nurses while excluding physicians?
It’s really all about the patient. Medical teams should be designed foremost to serve the patient. It seems like there should be a physician in there somewhere.

Global push to guarantee health coverage leaves U.S. behind

China, Mexico and other countries far less affluent are working to provide medical insurance for all citizens. It's viewed as an economic investment.

By Noam N. Levey, Washington Bureau
Los Angeles Times, May 12, 2012

WASHINGTON — Even as Americans debate whether to scrap President Obama’s healthcare law and its promise of guaranteed health coverage, many far less affluent nations are moving in the opposite direction — to provide medical insurance to all citizens.

China, after years of underfunding healthcare, is on track to complete a three-year, $124-billion initiative projected to cover more than 90% of the nation’s residents.

Mexico, which a decade ago covered less than half its population, just completed an eight-year drive for universal coverage that has dramatically expanded Mexicans’ access to life-saving treatments for diseases such as leukemia and breast cancer.

In Thailand, where the gross domestic product per person is a fifth of America’s, just 1% of the population lacks health insurance. And in sub-Saharan Africa, Rwanda and Ghana — two of the world’s poorest nations — are working to create networks of insurance plans to cover their citizens.

“This is truly a global movement,” said Dr. Julio Frenk, a former health minister in Mexico and dean of the Harvard School of Public Health. “As countries advance, they are realizing that creating universal healthcare systems is a necessity for long-term economic development.”

Many countries are still struggling to improve the quality of their medical care. And making healthcare affordable remains a challenge for most countries, as it does for the U.S., where about 15% of the population lacks coverage.

But the international drive to provide healthcare for everyone is increasingly leaving America behind.

“We are really an outlier,” said David De Ferranti, a former World Bank vice president who heads the Results for Development Institute, an international nonprofit based in Washington.

That stands in stark contrast to America’s historic leadership in education, he said. Long before most European countries, the United States ensured access to public schooling. Today, the U.S. is alone among the world’s richest nations in not providing healthcare coverage to all citizens.

Although the new U.S. health law is scheduled to do that in 2014, former Massachusetts Gov. Mitt Romney, the presumptive Republican presidential nominee, has promised to repeal it. Romney’s alternative does not include any provision to guarantee coverage.

Two decades ago, many former communist countries in Eastern Europe and elsewhere dismantled their universal healthcare systems amid a drive to set up free-market economies.

But popular demand for insurance protection has fueled an effort in nearly all of these countries to rebuild their systems. Similar pressure is coming from the citizens of fast-growing nations in Asia and Latin America, where rising living standards have raised expectations for better services.

Some countries have set up public systems like those in Great Britain or Canada. But many others are relying on a mix of government and commercial insurance, as in the U.S.

“People are demanding responses from their governments,” said Cristian Baeza, health director of the World Bank. Indeed, in countries such as India, politicians have learned that one of the surest ways to secure votes is to promise better access to healthcare.

In Chile, where free-market reforms eroded the country’s universal health system in the 1980s, a socialist candidate won the presidency in 2000 for the first time in nearly 30 years on a promise to renew guaranteed healthcare.

The Thai system, set up a decade ago, has survived years of political upheaval and a military coup. “No party dares touch it,” said Dr. Suwit Wibulpolprasert, a senior advisor to the Ministry of Public Health.

Many political leaders around the world also have concluded that creating a system of universal healthcare is crucial to remaining competitive globally and sustaining economic growth.

Chinese leaders were concerned their citizens were saving excessively because there was no system to protect them if they got seriously ill, said Yanzhong Huang, director of the Center for Global Health Studies at Seton Hall University. The high savings rate was restraining domestic demand for consumer items, making the economy overly dependent on selling goods abroad.

In Mexico, political leaders were alarmed to see that poor families were often forced to pull a child out of school or to give up productive assets such as livestock or equipment to pay medical bills, said Frenk, the former health minister.

Before embarking on its healthcare push, the Mexican government found that 4 million people every year were being driven into bankruptcy by illness. “That was a huge drag on the economy,” Frenk said.

Today, Mexico’s new government insurance plan — known as Seguro Popular — covers more than 50 million people, filling the gap left by the traditional health insurance system funded by payroll taxes.

Such steps don’t eliminate all financial strain on households. Indeed, in many poor nations that are expanding healthcare coverage, such as Vietnam and the Philippines, people still must pay most of their own medical bills, a sign of skimpy coverage.

Governments, too, feel the strain.Colombia’suniversal healthcare system, set up in 1993, has cost more than twice what was expected, said Ramiro Guerrero, a former vice minister of health.

Even so, there is growing evidence that universal coverage is protecting millions worldwide from financial ruin.

In Rwanda, researchers found that citizens who had joined one of the nation’s health plans were nearly 75% less likely to be hit with a catastrophic healthcare bill that threatened to bankrupt them.

And while the impact of broader coverage on overall health is still unclear, there are some signs that citizens of countries that are committed to guaranteeing health coverage are getting more treatment for serious illnesses.

In Mexico, the 30-month survival rate for children with cancer has more than doubled since the creation of the Seguro Popular program in 2003. In Ghana, visits to clinics and hospitals have doubled since the West African country passed a universal health law in 2003, said Nathaniel Otoo, general counsel for the National Health Insurance Authority of Ghana.

The universal system has also become a foundation for improving the quality of medical care in many countries such as China, where the government is now pushing a major overhaul in the way physicians are trained.

“That is the next challenge,” said Dr. Jeanette Vega, a former vice minister of health in Chile who is now managing director of the New York-based Rockefeller Foundation.

noam.levey@latimes.com

Copyright © 2012, Los Angeles Times

http://www.latimes.com/news/nationworld/nation/la-na-global-health-reform-20120512,0,4695600.story

Massachusetts group purchasers engaging in "benefit buy-down"

Massachusetts Health Care Cost Trends - Premiums and Expenditures

Commonwealth of Massachusetts
Health and Human Services, May 2012

The premium trends section of the report discusses trends in premiums paid by employers and consumers for health insurance, and the medical expenses and retention charges included in premiums. The analysis shows that the growth of premiums has slowed in recent years, although small groups continued to experience the highest adjusted premium rates and increases, and overall premium increases continue to outpace inflation. The slowing growth of premiums in Massachusetts is consistent with a national trend, suggesting that macroeconomic factors beyond the Commonwealth may be partially responsible. In addition, there is evidence that group purchasers are selecting insurance packages with fewer benefits or higher cost sharing requirements, a phenomenon known as “benefit buy-down.” Buy-down can result in lower observed premiums, but may reduce access to care or increase out-of-pocket expenditures.

http://www.mass.gov/eohhs/researcher/physical-health/health-care-delivery/health-care-cost-trends/2012-health-care-cost-trends/health-care-cost-trends-preliminary-reports/premiums-and-expenditures.html

Comment: 

By Don McCanne, MD

To no surprise, group purchasers in Massachusetts are engaging in “benefit buy-down” of health plans, which reduces access to care and increases out-of-pocket expenses for patients. Since the policies of the Affordable Care Act are very similar to the Massachusetts program, we can anticipate an acceleration of a national trend of benefit buy-down, establishing underinsurance as the new standard for the nation.

It doesn’t have be this way.