PNHP

“Global budgeting” for Children’s Hospital Boston

“Global budgeting” for Children’s Hospital Boston

Children’s, Blue Cross deal curbs payments

The Boston Globe
January 24, 2012

Children’s Hospital Boston has agreed to a three-year contract with Blue Cross Blue Shield of Massachusetts…

Perhaps most important, Children’s and its doctors groups will accept global payments for the first time, meaning they will be given a budget for patients’ care rather than billing for each visit and procedure.

“The contract is completely aligned with our aggressive and comprehensive efforts to take costs out of the system, while also improving quality,” said Children’s president Sandra Fenwick.

Until recently, it was thought unlikely that specialty providers such as Children’s, a 395-bed teaching hospital that is a national leader in pediatric research and training, would join the new global payment plans being offered by insurers.

Fenwick said the deal makes Children’s the first pediatric hospital in the nation to take global payments instead of traditional fee-for-service reimbursements. The contract also covers the Children’s Physicians Organization, made up of 959 specialists, and the Pediatric Physician Organization at Children’s, which includes 279 primary care doctors.

http://articles.boston.com/2012-01-24/business/30655411_1_pediatric-care-health-care-providers-specialty-hospitals

Comment: 

By Don McCanne, MD

Under a well designed single payer system, hospitals would be funded through global budgets, much like police and fire departments, libraries and other civic institutions. Single payer eliminates the need to provide complex, itemized billings for each and every patient to any of hundreds of third party payers. The hospitals are simply paid a global fee that covers all of their costs for the year. As Canada and other nations have shown, global budgeting dramatically reduces the high costs of the administrative excesses that U.S. hospitals face.

Blue Cross Blue Shield of Massachusetts has now negotiated the first contract with a pediatric hospital that they say uses global budgeting. So can we use this as an experiment to prove that global budgeting will work in the United States? Unfortunately, no.

This contract has almost nothing in common with global budgeting under a single payer system. A global budget limited to one insurer does not place the entire hospital under a single global budget. Far from it. They still have to interact with all other payers in our fragmented financing system. Further, the products and services provided to Blue Cross Blue Shield patients must be segregated and itemized separately to know the amount of the budget to be negotiated. The uncertainties on how to allocate various hospital costs also can result in inequities amongst the various payers, likely making Blue Cross Blue Shield a winner while other payers lose.

When we are told later on that we do not want hospitals globally budgeted under a single payer system because it did not work for Children’s Hospital Boston, be prepared to answer that this was not global budgeting. This was merely another individual contract between one hospital with its physicians’ organizations and one insurer, under a fragmented financing system in which it was impossible to achieve the efficiencies of globally budgeting of the hospital’s entire costs.

We can even invent a term based on what this process is. It is “segregated budgeting.” We can make that a pejorative term by demonstrating that it is merely another insurer gimmick in our dysfunctional system of financing health care. Let’s keep the definition of “global” clean, and not let the insurers steal it from us.

"Global budgeting" for Children's Hospital Boston

Children’s, Blue Cross deal curbs payments

The Boston Globe
January 24, 2012
Children’s Hospital Boston has agreed to a three-year contract with Blue Cross Blue Shield of Massachusetts…
Perhaps most important, Children’s and its doctors groups will accept global payments for the first time, meaning they will be given a budget for patients’ care rather than billing for each visit and procedure.
“The contract is completely aligned with our aggressive and comprehensive efforts to take costs out of the system, while also improving quality,” said Children’s president Sandra Fenwick.
Until recently, it was thought unlikely that specialty providers such as Children’s, a 395-bed teaching hospital that is a national leader in pediatric research and training, would join the new global payment plans being offered by insurers.
Fenwick said the deal makes Children’s the first pediatric hospital in the nation to take global payments instead of traditional fee-for-service reimbursements. The contract also covers the Children’s Physicians Organization, made up of 959 specialists, and the Pediatric Physician Organization at Children’s, which includes 279 primary care doctors.
http://articles.boston.com/2012-01-24/business/30655411_1_pediatric-care-health-care-providers-specialty-hospitals

Under a well designed single payer system, hospitals would be funded through global budgets, much like police and fire departments, libraries and other civic institutions. Single payer eliminates the need to provide complex, itemized billings for each and every patient to any of hundreds of third party payers. The hospitals are simply paid a global fee that covers all of their costs for the year. As Canada and other nations have shown, global budgeting dramatically reduces the high costs of the administrative excesses that U.S. hospitals face.
Blue Cross Blue Shield of Massachusetts has now negotiated the first contract with a pediatric hospital that they say uses global budgeting. So can we use this as an experiment to prove that global budgeting will work in the United States? Unfortunately, no.
This contract has almost nothing in common with global budgeting under a single payer system. A global budget limited to one insurer does not place the entire hospital under a single global budget. Far from it. They still have to interact with all other payers in our fragmented financing system. Further, the products and services provided to Blue Cross Blue Shield patients must be segregated and itemized separately to know the amount of the budget to be negotiated. The uncertainties on how to allocate various hospital costs also can result in inequities amongst the various payers, likely making Blue Cross Blue Shield a winner while other payers lose.
When we are told later on that we do not want hospitals globally budgeted under a single payer system because it did not work for Children’s Hospital Boston, be prepared to answer that this was not global budgeting. This was merely another individual contract between one hospital with its physicians’ organizations and one insurer, under a fragmented financing system in which it was impossible to achieve the efficiencies of globally budgeting of the hospital’s entire costs.
We can even invent a term based on what this process is. It is “segregated budgeting.” We can make that a pejorative term by demonstrating that it is merely another insurer gimmick in our dysfunctional system of financing health care. Let’s keep the definition of “global” clean, and not let the insurers steal it from us.

Principles for Cost-Effective, Sustainable Health Care Reform

By Stephen Kemble, M.D.

1.  Universality — single risk pool
2.  Standardized benefits, adequate for effective medically necessary care
3.  Minimize administration
4.  Promote professionalism in health care
5.  Quality improvement
6.  Ensure adequate professional workforce, especially for primary care
7.  Accountability must be to the health needs of the population
8.  Separate, sustainable funding for health care

1. Universality — single risk pool

Large health care savings become possible if competing plans are consolidated into a universal program with a single risk pool. This will eliminate insurance costs of underwriting, adverse selection, multiple private bureaucracies, brokers, lobbying, and marketing and advertising. Health plan incentives to avoid covering the sick and to “cherry pick” healthier subscribers and risk pools will be eliminated. There will be no pre-existing condition exclusions, cost-shifting, and disputes over who is responsible for paying for care. A broader risk pool will reduce per capita insurance reserve requirements. For businesses, a universal program will uncouple health insurance from employment status, and eliminate employer costs for health benefits administration. Patients will gain free choice of providers, with no restricted panels by plan. Everyone will have access to the same care, and the poor will no longer be relegated to an under-funded Medicaid program. The state will save the cost of eligibility determination for Medicaid. For care providers, there will be no uncompensated care. Universal coverage could remove health care costs from medical malpractice, worker’s compensation, and auto insurance, greatly reducing insurance costs, even without tort reform.

2. Standardized benefits, adequate for effective care

A universal program will require comprehensive benefits, adequate for all medically necessary care. Since those now covered under Medicaid will be included, co-pays and deductibles will have to be eliminated or so minimal that they could be waived for those who could not afford them. For the poor, there must be no financial barriers to seeking appropriate care. For those with moderate incomes, there will be no “under-insurance” or unaffordable costs for those with serious or disabling illness. Medical bankruptcy will be eliminated.

3. Minimize administration

With a universal program, billing and clams processing will be vastly simplified and standardized. Electronic health records and gathering of data for quality improvement will be standardized across all patients and providers. So will formulary and prior authorization policies for drugs. Incentives for cost-effectiveness should be at the point of service, between doctor and patient, minimizing central management of health care decisions by the program (managed care) with its high administrative costs. Global budgets for hospitals and integrated care systems will eliminate billing costs that can consume up to 20 percent of hospital budgets.

4. Promote professionalism in health care

In order to protect the public interest and safety, a universal health program must require maintenance of high standards for professional training. Professional scope of practice must be based on training, not lobbying. Physicians and other providers should be required to maintain membership in a professional organization, tied to licensure, to ensure that peer review and professional ethical standards are enforceable, and to promote continuing education. A universal program will also require organization of physicians and other professionals for negotiation of fees with the program, and for participation in quality improvement. The program should harness professionalism to keep health care equitable and cost-effective. The net income potential for professionals must be commensurate with the training and skills necessary for their scope of practice, and any reduction in professional pay must be tied to reduction in administrative burdens (cost, time, and hassles), reduced risk of lawsuits, and subsidies for training costs.

5. Quality Improvement

A system-wide quality improvement program with professional leadership should replace managed care administered by insurance companies. This program should follow William Deming’s Continuous Quality Improvement (CQI) model and focus on improving processes of care, rather than just HEDIS style quality measures. Unlike CQI, other strategies to reduce unnecessary and inappropriate care such as capitation, rating providers, pay-for-performance, and incentives based on outcomes are problematic because they create disincentives to treat difficult and complex patients.

6. Ensure adequate professional work force, especially for primary care

A universal program should improve payment for care coordination. Patients with significant chronic illnesses should be assigned to a “patient-centered medical home.” Primary care can also be encouraged with a state-level program similar to the National Health Service, with subsidies for medical education and training tied to commitment to practice in underserved areas and specialties.

7. Accountability must be to the health needs of the population

Health system policies, including fee structure, scope of practice issues, formularies, and covered benefits, must be set by a health authority that is accountable to the health needs of the community and insulated from special interests and lobbying. Funding for capital improvement in hospitals, nursing homes, diagnostic imaging centers, etc. should be determined by public health needs. Health care financing and institutions for delivery of care must both be not-for-profit. A universal health system will benefit from a continuous quality improvement program for administrative systems as well as for health care delivery, with robust feedback from providers and patients that can actually influence policies.

8. Separate, sustainable funding for health care

A universal health system must have its own separate funding stream, whether this is called a health tax or a premium. There must be no mixing of health care funding with general tax revenues. Funding must be responsive to actual costs of care and public health priorities.

Dr. Stephen Kemble is assistant professor of medicine at the University of Hawaii John A. Burns School of Medicine, and also in private practice as a general adult psychiatrist. He is a member of Physicians for a National Health Program. In September he was appointed by Hawaii’s Gov. Neil Abercrombie to the Hawaii Health Authority, charged with designing and then running a universal health care system for Hawaii.

This article originally appeared at OpEd News:
http://www.opednews.com/articles/Principles-for-Cost-Effect-by-Stephen-Kemble-111203-878.html

Ezekiel Emanuel wants liberals to worry about costs

What We Give Up for Health Care

By Ezekiel J. Emanuel
The New York Times, January 21, 2012

When it comes to health care, most liberals are committed above all to ensuring that every American has insurance. In their view, the greatest achievement of the health care reform act passed under President Obama is to finally erase the moral stain of the United States’ being the only major developed country without universal coverage. But we also hold the questionable distinction of having the world’s most expensive health care system — what about cost control? For many liberals, that just sounds like a cover for heartless conservatives who care only about cutting benefits and not about helping people in need.

But liberals are wrong to ignore costs. The more we spend on health care, the less we can spend on other things we value. If liberals care about middle-class salaries, public education and other state-funded services, then they need to care about controlling health care costs every bit as much as conservatives do.

During the campaign season and into 2013 — a vital year for health care legislation — liberals must make the issue of cost control their own.

(Ezekiel J. Emanuel is an oncologist, former White House adviser and a vice provost and professor at the University of Pennsylvania.)

http://opinionator.blogs.nytimes.com/2012/01/21/what-we-give-up-for-health-care/

Comment:

NYT Pick

Don McCanne
San Juan Capistrano, CA

Truly universal coverage and effective cost containment were the goals from the beginning, but Congress and the administration selected a model of reform that cannot possibly bring us either.

It is likely that tens of millions will remain uninsured because of affordability issues, and the measures supposedly designed to control costs will have very little impact. A new CBO report confirms that some of the mechanisms proposed have already been shown to be ineffective in pilot studies.

All other wealthy nations provide comprehensive services to everyone, and at prices that on average are half that of the United States. The other nations use similar technology, experience aging of their populations, and have similar rates of health care utilization, yet they are still able to contain their costs. The difference is that they have strong public oversight of their systems of social insurance or government health services.

Although single payer systems are well recognized for their savings through administrative efficiencies, they use many other tools to slow the increases in health care costs. These tools are not experimental, like those in the Affordable Care Act. They have already proven to be effective beyond any doubt in nations with such systems.

We can cover absolutely everyone, which should make the liberals happy, and we can do it while truly bringing our health care costs under control, and isn’t that what the conservatives want as well?

http://opinionator.blogs.nytimes.com/2012/01/21/what-we-give-up-for-health-care/?comments#permid=124

Ezekiel Emanuel wants liberals to worry about costs

What We Give Up for Health Care

By Ezekiel J. Emanuel
The New York Times, January 21, 2012
When it comes to health care, most liberals are committed above all to ensuring that every American has insurance. In their view, the greatest achievement of the health care reform act passed under President Obama is to finally erase the moral stain of the United States’ being the only major developed country without universal coverage. But we also hold the questionable distinction of having the world’s most expensive health care system — what about cost control? For many liberals, that just sounds like a cover for heartless conservatives who care only about cutting benefits and not about helping people in need.
But liberals are wrong to ignore costs. The more we spend on health care, the less we can spend on other things we value. If liberals care about middle-class salaries, public education and other state-funded services, then they need to care about controlling health care costs every bit as much as conservatives do.
During the campaign season and into 2013 — a vital year for health care legislation — liberals must make the issue of cost control their own.
(Ezekiel J. Emanuel is an oncologist, former White House adviser and a vice provost and professor at the University of Pennsylvania.)
http://opinionator.blogs.nytimes.com/2012/01/21/what-we-give-up-for-health-care/

Comment originally posted on the New York Times’ website.
NYT Pick
Don McCanne
San Juan Capistrano, CA
Truly universal coverage and effective cost containment were the goals from the beginning, but Congress and the administration selected a model of reform that cannot possibly bring us either.
It is likely that tens of millions will remain uninsured because of affordability issues, and the measures supposedly designed to control costs will have very little impact. A new CBO report confirms that some of the mechanisms proposed have already been shown to be ineffective in pilot studies.
All other wealthy nations provide comprehensive services to everyone, and at prices that on average are half that of the United States. The other nations use similar technology, experience aging of their populations, and have similar rates of health care utilization, yet they are still able to contain their costs. The difference is that they have strong public oversight of their systems of social insurance or government health services.
Although single payer systems are well recognized for their savings through administrative efficiencies, they use many other tools to slow the increases in health care costs. These tools are not experimental, like those in the Affordable Care Act. They have already proven to be effective beyond any doubt in nations with such systems.
We can cover absolutely everyone, which should make the liberals happy, and we can do it while truly bringing our health care costs under control, and isn’t that what the conservatives want as well?

U.S. to Sarah Burke's family: "Sorry for your loss; here's your bill"

'Sorry for your loss — here’s your bill'

By Robert Remington
Calgary Herald, January 20, 2012

With the family of deceased Canadian skier Sarah Burke facing a U.S. medical bill topping the value of an average Calgary home, I was reminded Friday of a quote by the late Justice Emmett Hall, a crusader for Canada’s public health-care system.

“We as a society are aware that the trauma of illness, the pain of surgery, the slow decline to death are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability,” Hall wrote in a 1979 review of publicly funded health insurance.

To help Burke’s husband Rory Bushfield pay an expected $550,000 medical bill for nine days of intensive care in Utah, a website was set up by Burke’s agent asking for donations. The site had reached nearly $200,000 as of this writing Friday afternoon, prompting the Canadian Freestyle Ski Association to announce that the amount was enough that her family “will not have any financial burden related to her care.”

The association’s statement seemed odd, considering that the website was $350,000 short of its intended goal, but not if you understand the vagaries of a private health system dominated by big private insurers.

In the U.S. health system, “nobody pays the sticker price, except for those who are squeezed, which is normally the uninsured,” says Steve Morgan, a health policy analyst with the University of British Columbia’s Centre for Health Services and Policy Research.

“Big insurance doesn’t pay retail,” Morgan says of the U.S. health system. Typically, he says a hospital will present a bill big enough to choke a horse and the insurance company will negotiate it down. Individuals without insurance, or those who are under-insured, have little or no negotiating power and often end up paying bills that are financially devastating, Morgan said.

Burke was apparently not adequately insured in the U.S. Her ski association only covers sanctioned events. Because the event at which she was injured and subsequently died was an unsanctioned competition put on by her sponsor, Monster Energy Company, the ski association’s insurance did not cover her.

It was not clear if Burke’s family thought she was adequately covered, or if Monster had insurance for her. The company did not say if it would help cover her medical bills, which Morgan says is not surprising.

Monster, he said, could have negotiated behind the scenes to get the price down. The Canadian Freestyle Ski Association said the family had not yet received a final bill for her hospitalization, but that it is expected to be approximately $200,000, roughly the amount that had already been collected.

Morgan says Burke’s case should be a sobering reminder to Canadians of what could happen in a privately-insured market, rather than a public system where everyone is insured against a catastrophic event.

In 2000, the U.S. health policy journal Health Affairs wrote about the issue under the heading “Gouging the Medically Uninsured: A Tale of Two Bills.”

“Overcharging the uninsured is one of the many unintended and largely overlooked results of our decade-long obsession with curbing health-care costs,” it said. “Powerful interest groups — government, employers, insurers, hospitals, medical equipment vendors, and health care professionals — have fought vigorously to protect their interests. The uninsured, with no organized voice, emerge as losers.”

Since 2001, family health insurance premiums in the U.S. have increased 113 per cent, according to the Kaiser Family Foundation, with annual premiums for employer-sponsored family health coverage growing to $15,073 in 2011. Due to the economic downturn, the number of Americans going without insurance has grown by one million to 49.9 million people.

We complain of health-care costs and outcomes in Canada, but the U.S. ranks behind Australia, Canada, Germany, the Netherlands, New Zealand and the U.K. in five areas of health system performance: quality, efficiency, access to care, equity and mortality, according to a report by the Commonwealth Fund.

“Our failure as a country to ensure basic health care for all of its citizens is in part to blame,” Glenn D. Braunstein, chairman of the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles, wrote Friday in the Huffington Post.

It is, indeed, a sobering reminder to Canadians how lucky we are. As one commentator wrote of the Burke family’s experience with the U.S. system: “We are sorry for your loss. Here’s your bill.”

http://www.calgaryherald.com/opinion/Remington+Sorry+your+loss+here+your+bill/6029293/story.html

Comment: 

By Don McCanne, MD

Instead of commenting on the cruel and inhumane health care financing system we have in the United States, let’s remember Sarah by spending a moment with her:

http://www.youtube.com/watch?v=O4tQJAl4tYM

U.S. to Sarah Burke’s family: “Sorry for your loss; here’s your bill”

‘Sorry for your loss — here’s your bill’

By Robert Remington
Calgary Herald, January 20, 2012

With the family of deceased Canadian skier Sarah Burke facing a U.S. medical bill topping the value of an average Calgary home, I was reminded Friday of a quote by the late Justice Emmett Hall, a crusader for Canada’s public health-care system.

“We as a society are aware that the trauma of illness, the pain of surgery, the slow decline to death are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability,” Hall wrote in a 1979 review of publicly funded health insurance.

To help Burke’s husband Rory Bushfield pay an expected $550,000 medical bill for nine days of intensive care in Utah, a website was set up by Burke’s agent asking for donations. The site had reached nearly $200,000 as of this writing Friday afternoon, prompting the Canadian Freestyle Ski Association to announce that the amount was enough that her family “will not have any financial burden related to her care.”

The association’s statement seemed odd, considering that the website was $350,000 short of its intended goal, but not if you understand the vagaries of a private health system dominated by big private insurers.

In the U.S. health system, “nobody pays the sticker price, except for those who are squeezed, which is normally the uninsured,” says Steve Morgan, a health policy analyst with the University of British Columbia’s Centre for Health Services and Policy Research.

“Big insurance doesn’t pay retail,” Morgan says of the U.S. health system. Typically, he says a hospital will present a bill big enough to choke a horse and the insurance company will negotiate it down. Individuals without insurance, or those who are under-insured, have little or no negotiating power and often end up paying bills that are financially devastating, Morgan said.

Burke was apparently not adequately insured in the U.S. Her ski association only covers sanctioned events. Because the event at which she was injured and subsequently died was an unsanctioned competition put on by her sponsor, Monster Energy Company, the ski association’s insurance did not cover her.

It was not clear if Burke’s family thought she was adequately covered, or if Monster had insurance for her. The company did not say if it would help cover her medical bills, which Morgan says is not surprising.

Monster, he said, could have negotiated behind the scenes to get the price down. The Canadian Freestyle Ski Association said the family had not yet received a final bill for her hospitalization, but that it is expected to be approximately $200,000, roughly the amount that had already been collected.

Morgan says Burke’s case should be a sobering reminder to Canadians of what could happen in a privately-insured market, rather than a public system where everyone is insured against a catastrophic event.

In 2000, the U.S. health policy journal Health Affairs wrote about the issue under the heading “Gouging the Medically Uninsured: A Tale of Two Bills.”

“Overcharging the uninsured is one of the many unintended and largely overlooked results of our decade-long obsession with curbing health-care costs,” it said. “Powerful interest groups — government, employers, insurers, hospitals, medical equipment vendors, and health care professionals — have fought vigorously to protect their interests. The uninsured, with no organized voice, emerge as losers.”

Since 2001, family health insurance premiums in the U.S. have increased 113 per cent, according to the Kaiser Family Foundation, with annual premiums for employer-sponsored family health coverage growing to $15,073 in 2011. Due to the economic downturn, the number of Americans going without insurance has grown by one million to 49.9 million people.

We complain of health-care costs and outcomes in Canada, but the U.S. ranks behind Australia, Canada, Germany, the Netherlands, New Zealand and the U.K. in five areas of health system performance: quality, efficiency, access to care, equity and mortality, according to a report by the Commonwealth Fund.

“Our failure as a country to ensure basic health care for all of its citizens is in part to blame,” Glenn D. Braunstein, chairman of the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles, wrote Friday in the Huffington Post.

It is, indeed, a sobering reminder to Canadians how lucky we are. As one commentator wrote of the Burke family’s experience with the U.S. system: “We are sorry for your loss. Here’s your bill.”

http://www.calgaryherald.com/opinion/Remington+Sorry+your+loss+here+your+bill/6029293/story.html

Comment: 

By Don McCanne, MD

Instead of commenting on the cruel and inhumane health care financing system we have in the United States, let’s remember Sarah by spending a moment with her:

http://www.youtube.com/watch?v=O4tQJAl4tYM

Debt, Deficit Denial: Why We Must Fix U.S. Health Care

By Glenn D. Braunstein, M.D.
The Huffington Post, Jan. 17, 2012

As partisans wrangle over fiscal matters like entitlements and taxes, what is getting overlooked is the more real and basic need to reform a huge and inefficient driver of America’s economy: our health care delivery system. We spend far more than any other country on health care. Yet our citizens don’t live as long as people in many other countries. Many of our health outcomes lag far behind other developed nations. The disparities in even basic care are too great between rich and poor. And too many Americans lack basic health insurance coverage.

The costs of providing health care in this country grow ever more painful and unsustainable. We spend $7,538 per person on health care, the highest rate in the industrialized world. That’s more than twice the average amount spent by 15 countries analyzed by the Organization for Economic Cooperation and Development.

Even if you’ve still got a job with decent health insurance, skyrocketing costs affect you. Since 2001, the Kaiser Family Foundation reports, family health insurance premiums have increased 113 percent; annual premiums for employer-sponsored family health coverage grew to $15,073 this year, up 9 percent from last year.

Big Costs, Shortfalls in Care

For the enormous sums we plow into health care, we might at least expect every American to get needed medical care. Not so. We also might expect that we would live longer, healthier lives than anyone on the face of the earth. Also, not so.

Compared to Australia, Canada, Germany, the Netherlands, New Zealand and the United Kingdom, the U.S. comes in dead last in five areas of health system performance: quality, efficiency, access to care, equity and the ability to lead long, healthy productive lives, reports the Commonwealth Fund, a foundation supporting independent research on health care issues.

The U.S. ranks last on measures of safe patient care, and second to last on coordinated care. We also came in last in infant mortality and on potentially preventable deaths before age 75. Overall, we don’t live as long as people in those developed countries. Our failure as a country to ensure basic health care for all of its citizens is in part to blame. The most recent report from the U.S. Census Bureau shows that the number of uninsured Americans has ticked up to 49.9 million people, up from 49.0 million in 2009. The increase, while small, is significant to the one million or so more people no longer covered. In California, nearly one in five residents lacked health insurance in 2010, the eighth highest rate in the nation. That hits hard for 7.2 million Californians affected.

The current economic downturn is adding to our health problems. Some 15 percent of people ages 18 to 64 say they have delayed or avoided medical care because of the cost, and 11 percent didn’t fill their prescription orders due to cost. Health insurance coverage for most of us today is subject to change if we shift jobs or lose our work, if we marry or if we divorce. Studies have shown that people without health insurance suffer more disease and don’t live as long as people with insurance, and the downward spiral in health is even greater for people in their 50s and 60s. Because so many of us are a pink slip away from losing health insurance, and with the endemic job cuts we’ve seen recently, by the time big parts of the Boom Generation hit the Medicare magic age of 65, they well could end up costing the system more to make up for unmet needs.

Another big problem with having so many uninsured people is that they have less access to preventive and continuing care, so often the only way they then can get services is via the Emergency Room.

If our nation’s health care system could get these sick folks covered and make it easier for them to get preventive care, we could both improve their health and provide primary care in a much more efficient way than through the Emergency Room.

When the uninsured need ER care, hospitals provide for them, regardless of their ability to pay. There are costs for that unpaid care, however, and they’re now shifted onto others in the system: Doctors and hospitals find they must increase their charges to paying patients to provide emergency care for the uninsured; patients with insurance, in turn, submit higher medical bills to their insurers, who, in turn, increase premiums for us all.

What once were confident comparisons with health-care systems in Canada and Europe — replete with suggestions that Americans don’t have to wait in line for appointments and can get costly treatments even if they are old and infirm — have faded. Now, it’s rare for politicians to boldly state, as they often did even a few years ago, that America is the best place on earth to be if you happen to get sick.

A Big ‘Yes!’ for Universal Access

As a physician at a large nonprofit academic medical center that cares for many uninsured and underinsured patients, I strongly advocate for universal coverage for basic medical care, which will provide access to health care for everyone.

The health reform legislation that some opponents are so eager to kill — without providing concrete, sound alternatives — could push the country to a better place by covering 30 million more Americans.

That’s good, though it could be better, and I would underscore my belief that the wealthiest nation in the world ought to provide all its citizens with access to health care. Universal coverage is essential, but by no means is it the only change required. We also must curb rising costs through an array of means — and universal coverage, research shows, could play a role in this.

Ideally, this would be an extension of a Medicare or Medicaid type of program to every American without any age or income requirement, providing cradle-to-grave coverage. To maintain equity of care and benefits, as well as the economic savings that would come with a single infrastructure and the purchasing power that a large program would enjoy, I feel that a federally run, single-payer system for basic care would be best. Expecting the government to provide for our health and well-being is no more of a socialist concept than our expectations that government should provide universal protection from fire and crime and be responsible for our national security.

I also believe that the system should be financed through taxes and that there should be a means test — those who make more should pay more for this coverage.

And because we’re an outstanding example of a capitalist democracy, we need to accept a two-tier health system with everybody receiving basic coverage, while those who can afford it can use their own money or buy more insurance to pay for levels of service that may not be included in the basics. And by additional levels of service, I don’t just mean medical luxuries like facelifts, tummy tucks and vision-correcting laser surgery. Those who can afford it, may be able to fly around to find top experts in the country or speed up the timing of an elective surgery. It’s fair that they can choose such options, and it’s also fair that they’re on their own in paying for the upgrades.

In the next few months, I’ll offer some additional prescriptions for how all of us, including physicians like me and other caregivers, might improve our health care system. In this great country of ours, we may face fiscal shortfalls, but the disparities we face in getting and keeping folks well cannot be tolerated. As Americans we’ve never had a deficit in our ideas, aspirations and our will to see all our friends and neighbors live healthier, better and longer. Our health care system is sick and we must attend to it before it collapses.

Dr. Glenn Braunstein is professor and chairman of t
he Department of Medicine at Cedars-Sinai Medical Center in Los Angeles, where he holds the James R. Klinenberg Chair in Medicine.

http://www.huffingtonpost.com/glenn-d-braunstein-md/universal-health-care_b_1208977.html

‘Sorry for your loss — here’s your bill’

By Robert Remington
Calgary Herald, Jan. 20, 2012

With the family of deceased Canadian skier Sarah Burke facing a U.S. medical bill topping the value of an average Calgary home, I was reminded Friday of a quote by the late Justice Emmett Hall, a crusader for Canada’s public health-care system.

“We as a society are aware that the trauma of illness, the pain of surgery, the slow decline to death are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability,” Hall wrote in a 1979 review of publicly funded health insurance.

To help Burke’s husband Rory Bushfield pay an expected $550,000 medical bill for nine days of intensive care in Utah, a website was set up by Burke’s agent asking for donations. The site had reached nearly $200,000 as of this writing Friday afternoon, prompting the Canadian Freestyle Ski Association to announce that the amount was enough that her family “will not have any financial burden related to her care.”

The association’s statement seemed odd, considering that the website was $350,000 short of its intended goal, but not if you understand the vagaries of a private health system dominated by big private insurers.

In the U.S. health system, “nobody pays the sticker price, except for those who are squeezed, which is normally the uninsured,” says Steve Morgan, a health policy analyst with the University of British Columbia’s Centre for Health Services and Policy Research.

“Big insurance doesn’t pay retail,” Morgan says of the U.S. health system. Typically, he says a hospital will present a bill big enough to choke a horse and the insurance company will negotiate it down. Individuals without insurance, or those who are under-insured, have little or no negotiating power and often end up paying bills that are financially devastating, Morgan said.

Burke was apparently not adequately insured in the U.S. Her ski association only covers sanctioned events. Because the event at which she was injured and subsequently died was an unsanctioned competition put on by her sponsor, Monster Energy Company, the ski association’s insurance did not cover her.

It was not clear if Burke’s family thought she was adequately covered, or if Monster had insurance for her. The company did not say if it would help cover her medical bills, which Morgan says is not surprising.

Monster, he said, could have negotiated behind the scenes to get the price down. The Canadian Freestyle Ski Association said the family had not yet received a final bill for her hospitalization, but that it is expected to be approximately $200,000, roughly the amount that had already been collected.

Morgan says Burke’s case should be a sobering reminder to Canadians of what could happen in a privately-insured market, rather than a public system where everyone is insured against a catastrophic event.

In 2000, the U.S. health policy journal Health Affairs wrote about the issue under the heading “Gouging the Medically Uninsured: A Tale of Two Bills.”

“Overcharging the uninsured is one of the many unintended and largely overlooked results of our decade-long obsession with curbing health-care costs,” it said. “Powerful interest groups — government, employers, insurers, hospitals, medical equipment vendors, and health care professionals — have fought vigorously to protect their interests. The uninsured, with no organized voice, emerge as losers.”

Since 2001, family health insurance premiums in the U.S. have increased 113 per cent, according to the Kaiser Family Foundation, with annual premiums for employer-sponsored family health coverage growing to $15,073 in 2011. Due to the economic downturn, the number of Americans going without insurance has grown by one million to 49.9 million people.

We complain of health-care costs and outcomes in Canada, but the U.S. ranks behind Australia, Canada, Germany, the Netherlands, New Zealand and the U.K. in five areas of health system performance: quality, efficiency, access to care, equity and mortality, according to a report by the Commonwealth Fund.

“Our failure as a country to ensure basic health care for all of its citizens is in part to blame,” Glenn D. Braunstein, chairman of the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles, wrote Friday in the Huffington Post.

It is, indeed, a sobering reminder to Canadians how lucky we are. As one commentator wrote of the Burke family’s experience with the U.S. system: “We are sorry for your loss. Here’s your bill.”

Robert Remington is a Herald editorial writer and columnist.

http://www.calgaryherald.com/health/Remington+Sorry+your+loss+here+your+bill/6029293/story.html#ixzz1kIKvEvDd

U.S. to Sarah Burke's family: "Sorry for your loss; here's your bill"

‘Sorry for your loss — here’s your bill’

By Robert Remington
Calgary Herald, January 20, 2012
With the family of deceased Canadian skier Sarah Burke facing a U.S. medical bill topping the value of an average Calgary home, I was reminded Friday of a quote by the late Justice Emmett Hall, a crusader for Canada’s public health-care system.
“We as a society are aware that the trauma of illness, the pain of surgery, the slow decline to death are burdens enough for the human being to bear without the added burden of medical or hospital bills penalizing the patient at the moment of vulnerability,” Hall wrote in a 1979 review of publicly funded health insurance.
To help Burke’s husband Rory Bushfield pay an expected $550,000 medical bill for nine days of intensive care in Utah, a website was set up by Burke’s agent asking for donations. The site had reached nearly $200,000 as of this writing Friday afternoon, prompting the Canadian Freestyle Ski Association to announce that the amount was enough that her family “will not have any financial burden related to her care.”
The association’s statement seemed odd, considering that the website was $350,000 short of its intended goal, but not if you understand the vagaries of a private health system dominated by big private insurers.
In the U.S. health system, “nobody pays the sticker price, except for those who are squeezed, which is normally the uninsured,” says Steve Morgan, a health policy analyst with the University of British Columbia’s Centre for Health Services and Policy Research.
“Big insurance doesn’t pay retail,” Morgan says of the U.S. health system. Typically, he says a hospital will present a bill big enough to choke a horse and the insurance company will negotiate it down. Individuals without insurance, or those who are under-insured, have little or no negotiating power and often end up paying bills that are financially devastating, Morgan said.
Burke was apparently not adequately insured in the U.S. Her ski association only covers sanctioned events. Because the event at which she was injured and subsequently died was an unsanctioned competition put on by her sponsor, Monster Energy Company, the ski association’s insurance did not cover her.
It was not clear if Burke’s family thought she was adequately covered, or if Monster had insurance for her. The company did not say if it would help cover her medical bills, which Morgan says is not surprising.
Monster, he said, could have negotiated behind the scenes to get the price down. The Canadian Freestyle Ski Association said the family had not yet received a final bill for her hospitalization, but that it is expected to be approximately $200,000, roughly the amount that had already been collected.
Morgan says Burke’s case should be a sobering reminder to Canadians of what could happen in a privately-insured market, rather than a public system where everyone is insured against a catastrophic event.
In 2000, the U.S. health policy journal Health Affairs wrote about the issue under the heading “Gouging the Medically Uninsured: A Tale of Two Bills.”
“Overcharging the uninsured is one of the many unintended and largely overlooked results of our decade-long obsession with curbing health-care costs,” it said. “Powerful interest groups — government, employers, insurers, hospitals, medical equipment vendors, and health care professionals — have fought vigorously to protect their interests. The uninsured, with no organized voice, emerge as losers.”
Since 2001, family health insurance premiums in the U.S. have increased 113 per cent, according to the Kaiser Family Foundation, with annual premiums for employer-sponsored family health coverage growing to $15,073 in 2011. Due to the economic downturn, the number of Americans going without insurance has grown by one million to 49.9 million people.
We complain of health-care costs and outcomes in Canada, but the U.S. ranks behind Australia, Canada, Germany, the Netherlands, New Zealand and the U.K. in five areas of health system performance: quality, efficiency, access to care, equity and mortality, according to a report by the Commonwealth Fund.
“Our failure as a country to ensure basic health care for all of its citizens is in part to blame,” Glenn D. Braunstein, chairman of the Department of Medicine at Cedars-Sinai Medical Center in Los Angeles, wrote Friday in the Huffington Post.
It is, indeed, a sobering reminder to Canadians how lucky we are. As one commentator wrote of the Burke family’s experience with the U.S. system: “We are sorry for your loss. Here’s your bill.”
http://www.calgaryherald.com/opinion/Remington+Sorry+your+loss+here+your+bill/6029293/story.html

Instead of commenting on the cruel and inhumane health care financing system we have in the United States, let’s remember Sarah by spending a moment with her:

http://www.youtube.com/watch?v=O4tQJAl4tYM

Do we need to gut MaineCare?

By Philip Caper, M.D.
Bangor Daily News, Jan. 19, 2012

For more than a month, the Legislature has been focused on the governor’s proposal to cut $221 million from the Department of Health and Human Services budget by revoking Medicaid eligibility for about 65,000 low-income and disabled Mainers. His proposal has generated controversy, including marathon hearings, state house rallies, articles in many of Maine’s papers as well as a petition that garnered more than 8,000 signatures in less than two weeks, all opposing the cuts.

I hope our legislators are enjoying this exercise in democracy because, even if they are able to satisfactorily resolve the immediate crisis, they can look forward to a repeat performance in a year or two unless they have the courage, wisdom and bipartisanship to attack the fundamental flaws in the ways we finance and deliver health care services. Maine’s very real problems with MaineCare are only symptoms of defects in our overall health care system. The most visible signs are out-of-control costs and diminishing access to quality health care.

For the past few decades, insurance companies have been systematically pushing the least healthy off their rolls. As a result, many people have been forced to turn to public programs such as Medicaid, swelling its rolls, or to their own inadequate resources. Predictably, the amount of uncompensated care facing hospitals and other providers is growing. The Maine Hospital Association recently sounded the alarm, warning that layoffs and further reductions in service would result from the proposed MaineCare cutbacks.

Attempts in the past to slow this trend by tinkering with the existing employment-based system have not succeeded. Our health care system does not need a tune-up. It needs an overhaul. And it must begin with the way we finance health care.

As the MaineCare hearings are demonstrating, our current fragmented system of financing health care breeds conflict. We have separate financing systems for different groups. Each constituency is focused on protecting its own program, often without regard to the effect on others. Each may believe they are being asked unfairly to shoulder somebody else’s burden. The result is stalemate.

That is one reason to move from our fragmented financing system to a single publicly managed pool in which everyone would participate. All would play by the same rules and eligibility issues would be moot. Questions of fairness among groups of people would largely disappear and our health care version of class warfare would be eliminated. Such a program’s universal base of beneficiaries would protect the plan’s popularity, funding and political viability. Care that exceeds the program’s benefits could be purchased privately.

In addition to simplifying administrative costs, this program could ratchet down out-of-control prices and windfall incomes and profits by individuals and corporations. Centralizing health care data would make it much easier to detect fraud, waste and abuse.

More than enough money to cover everybody would be freed up. It is credibly estimated that such a program could result in saving the people of Maine more than $1 billion dollars in the first year alone, and all but eliminate the pain and suffering created by fighting arbitrary insurance company denials. These changes would accelerate reforms in the way we pay purveyors of medical goods and services. That would permanently reduce the rate of future inflation of health care costs.

Some believe Americans will not give up choice of insurance plans. In my experience, people want a choice of health care providers but don’t much care who finances their care. Medicare, run by the much-maligned federal government, is very popular.

Maybe it’s time to have a serious public discussion about health care reform in Maine. It could start with updating the 2002 study of the feasibility of a single-payer health plan for Maine. That study concluded such a plan would be feasible.

Such a study could be privately funded and not have to wait for legislative approval. There are many public-service-oriented organizations in Maine that have the resources to take on the task. They are already pursuing useful projects, and I believe many of them privately understand the need for the type of changes I am recommending. But thus far they have been reluctant to actively advance the kind of systemic overhaul I recommend.

Maybe it’s time for them to step up to the plate and take notice of the elephant in the room. If we don’t undertake bold reform of our health care system soon, the legislature and the people of Maine are in for more tragic infighting. The losers will be all of us.

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

http://bangordailynews.com/2012/01/19/health/do-we-need-to-gut-mainecare/ printed on January 20, 2012

Reinhardt: Is U.S. Health Spending Finally Under Control?

Is U.S. Health Spending Finally Under Control?

By Uwe E. Reinhardt
The New York Times, January 20, 2012

“Growth in U.S. health spending remains slow in 2010” was the headline of a news release on Jan. 9 by the Centers for Medicare and Medicaid Services, part of the Department of Health and Human Services. At an increase of 3.9 percent over national health spending in 2009, “the rates of health spending growth in 2009 and 2010 marked the lowest rate in the 51-year history of the National Health Expenditure Accounts,” the release said.

The $64,000 question is how soon the excess growth of health spending will descend from its historical average of 1.5 to 2.5 percent first to, say, 1 percent or so, and eventually to 0 percent.

It is tempting to view the relatively lower cost growth in recent years as a first step in that direction. But nothing in the history of health spending in the United States suggests that this is the time to break out the Champagne to celebrate that victory.

After all, low rates of spending increases in 2009-10 could just be the lagged effect of the deep recession in 2008-9. There is evidence in the literature that health spending does not completely march to its own drummer, regardless of what happens in the rest of the economy, but instead tends to rise and fall somewhat with the rest of the G.D.P., albeit with a lag of one to two years. The safest bet is that on the long road to eventual zero excess growth in health spending, we will ride up and down quite a few more times on the health-spending roller coaster.

Now why is it reasonable to assume that excess cost growth will just have to decline to zero in the long run – that is, to assume that health spending will not eventually grow faster than G.D.P. and perhaps even more slowly?

Economists would explain such a trend as follows: as the fraction of G.D.P. devoted to health care increases, the added satisfaction, or utility, that people derive from added health care is likely to diminish relative to the added satisfaction derived from consuming more of other things. It could explain a gradual decline in the excess growth of health care spending.

Finally, economists retreat here to the one law on which they all agree, namely, Stein’s Law, named for the late economist Herbert Stein: “If something cannot go on forever, it will stop.” Trust us. It will, in the long run.

http://economix.blogs.nytimes.com/2012/01/20/is-u-s-health-spending-finally-under-control/

Published Comment:

Don McCanne
San Juan Capistrano, CA

How close we already are to meeting the limits of Stein’s Law is exemplified by 1) the current cost of health care for a family of four with an employer-sponsored PPO – $19,393 (Milliman), and 2) median household income – $49,445 (2010).

Although these are not measures of identical family units, they do provide enough of a perspective to show that we have run out of space in family budgets to pay for health care. The forgoing of wages to pay for employer-sponsored health benefits has crimped family budgets to the extent that frugality has become, by necessity, the norm.

We can continue as we are, allowing personal hardship to increase, or we can have our public stewards take control, as they have in other nations. They have been successful in ensuring that everyone has health care at costs averaging only half of those in the U.S.

A properly designed Medicare for all would work just fine for all of us.