Resource – Page 61

How Financial Incentives for Quality Metrics Hurt Us

Summary: An excellent commentary describes how two decades of paying to improve quality metrics has failed. Quality hasn’t improved, and we’ve spent billions of dollars and hours on quality indicators of dubious validity. We’ve compromised the practice of medicine, and increased disparities. Universal insurance is the foundation for improving quality.

Reassessing Quality Assessment – The Flawed System for Fixing a Flawed System, New England Journal of Medicine, April 13, 2022, by Lisa Rosenbaum, M.D.

[R]ecently, there has been growing recognition of the QI movement’s shortcomings. One study, for instance, showed that only 37% of MIPS measures for ambulatory internal medicine were valid, and even CMS and the Government Accountability Office have acknowledged the need to improve the quality of measuring quality. …

[O]nce a measure is implemented and tied to a financial incentive, an entire industry arises to boost organizations’ scores on that measure. Consultants get hired. Electronic health records (EHRs) are changed. And the measures become a source of intense organizational focus. Not only does it become difficult to modify measures that aren’t clearly working, but a tremendous amount of resources are directed toward the appearance of quality rather than its substance. …

[V]alue-based payment initiatives can also worsen inequities, even though addressing them ought to be at the forefront of our QI efforts. Indeed, after implementation of CMS’s value-based purchasing programs, safety-net hospitals disproportionately bore the brunt of financial penalties. In 2019, hospitals caring for a high percentage of Black patients were disproportionately likely to incur financial penalties. And hospitals serving the highest-risk patients incurred the largest penalties under the HRRP, independent of quality of care. Billions of dollars are thus being transferred from poorly resourced hospitals or those serving the sickest patients to well-resourced hospitals, worsening the disparities we claim to be trying to fix.

Punishing the hospitals and patients most in need of support makes “zero sense,” says Wadhera. He notes the broader irony of attempting to reduce spending with programs that create untold administrative costs and possibly greater net costs to the system long term. For instance, smaller practices that are unable to afford these administrative costs are increasingly being bought by larger health systems that sometimes charge higher prices. And though such consequences create hard-to-quantify indirect costs, truly unquantifiable is the loss to society as consummate community physicians become a dying breed. “Community doctors want to practice medicine,” said Wadhera. “They don’t want to practice quality measurement.”

Some early QI leaders recognized the risk of demoralizing the workforce.

Comment:

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

This thoughtful perspective highlights critical points about our efforts to improve quality with financial incentives, often under the rubric of “value-based care”.

First, financial incentives largely failed to improve quality. There have been a few focal benefits, but rare.

Second, they harm the practice of medicine, by distracting physicians from a focus on clinical care to documentation of quality metrics.

Third, and related, the imperative to increase revenue with quality scores makes coding even more onerous. Unwelcome added time in the EHR is the result.

Fourth, medicine “plays to the code” – any modest gains in measured tasks result in less attention to important quality activities that aren’t in the metric set.

Fifth, the onerous requirements for all this coding, too much for small physician offices, instigated a shift to corporate ownership of providers. That increases costs. (And makes medicine more corporate, which many of us dislike.)

Finally, disparities – inferior resources for the poor and sick – are exacerbated. Exactly the opposite of what we want.

The poor theoretical basis of financial incentives in medicine was pointed out long ago, by among others two HJM bloggers and a behavioral economist. Financial incentives diminish the intrinsic motivation that is so widespread and valuable in medicine.

Recently, several leaders in quality improvement described well the failings of numerical quality scores and proposed a new “criterion” approach. The details need working out, but the move away from competitive scoring linked to reimbursement is very welcome indeed.

The other critical element of improving quality is to remove the distraction of missing, inadequate, and inconsistent insurance. Just cover everybody, with exactly the same benefits and same payments. (Single payer!) Let physicians focus on their clinical mission, provide resources to help them keep improving, and measure success with non-punitive outcome tracking and by talking with patients.

http://healthjusticemonitor.org…

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

Congenital Syphilis Deaths Should Be a Wake-Up Call

Summary: More fetuses and babies are dying from syphilis, a completely preventable outcome with adequate access to quality prenatal care. This is a another marker of failure of our systems for health care financing and public health.

Babies Die as Congenital Syphilis Continues a Decade-Long Surge Across the US, California Healthline, April 12, 2022, by Anna Maria Barry-Jester

For a decade, the number of babies born with syphilis in the U.S. has surged, undeterred. Data released Tuesday by the Centers for Disease Control and Prevention shows just how dire the outbreak has become.

In 2012, 332 babies were born infected with the disease. In 2021, that number had climbed nearly sevenfold, to at least 2,268, according to preliminary estimates. And 166 of those babies died.

About 7% of babies diagnosed with syphilis in recent years have died; thousands of others born with the disease have faced problems that include brain and bone malformations, blindness, and organ damage.

“The really depressing thing about it is we had this thing virtually eradicated back in the year 2000,” said William Andrews, a public information officer for Oklahoma’s sexual health and harm reduction service.

From 2011 through 2020, congenital syphilis resulted in 633 documented stillbirths and infant deaths, according to the new CDC data.

Comment:

By Don McCanne, M.D.

Though we spend far more per capita on health care than any other nation, we have a flawed health care financing system that leaves millions who are insured in financial hardship and millions more with no insurance coverage at all. We finance our health care delivery system in a manner designed to create personal wealth for a few while failing to ensure health care access for all.

At least in the past we could be proud of some of the basics of our health care system such as the provision of prenatal and other public health services that reduced afflictions such as congenital syphilis. But public health capacity has decreased, and recent statistics demonstrate that we are moving backwards even in basic disease control that we previously took for granted. Shockingly, maternal mortality is also rising.

So where are we? Our partly public health care financing system is becoming more privatized, and our health care delivery system is experiencing increasing dominance by private equity firms and other corporate middlemen. And now our public health delivery is becoming more reliant on the private sector. On all three levels – our system of financing health care, ownership of health care delivery, and our support of our public health services – we are failing. We spend enough money (the public’s money either directly or indirectly) but fall short on much-needed public oversight.

One little niche in which we are beginning to fulfill the American entrepreneurial dream – the manufacture and marketing of infant caskets. (Excuse me while I attempt to wipe the tears from my eyes.)

http://healthjusticemonitor.org…

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Medicare for All Explained Podcast: Episode 75

Congressional testimony from economist Jeffrey Sachs

April 15, 2022

Podcast host Joe Sparks highlights the testimony of economist Jeffrey Sachs during a recent U.S. House Committee on Oversight and Reform hearing on “Examining Pathways to Universal Health Coverage.” During his opening remarks, Sachs told the committee that we don’t have a health care system in the U.S.

“What we have is a scam.”

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

https://medicareforallexplained.podbean.com

Full opening remarks from Jeffrey Sachs

Medicare Advantage Costly Diagnostic Upcoding

Summary: Investigative reporting by Bloomberg highlights the work of whistleblowers and the federal government to combat fraudulent upcoding by Medicare Advantage plans. But Medicare itself greatly worsens the problem, by failing to properly regulate aggressive (largely legal) upcoding.

Major Insurers Are Scamming Billions from Medicare, Whistle-Blowers Say, Bloomberg, April 12, 2022, by John Tozzi

Each year, [Medicare Advantage] plans submit giant data files to Medicare with diagnostic codes meant to reflect their members’ illnesses. Those codes determine how much they get paid. A federal watchdog warned in March that coding differences brought Medicare Advantage plans $12 billion in excess payments in 2020, compared to what traditional Medicare would have paid to cover the same population. The cumulative extra payments since 2007 will soon top $100 billion, according to the Medicare Payment Advisory Commission, or MedPAC. …

The Department of Justice called policing Medicare Advantage an important priority on its anti-fraud agenda. The agency said in February that it pursued health plans that gamed the system “by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were,” …

Health-care companies developed increasingly sophisticated methods to maximize payments. A cottage industry of vendors emerged to help them. They mine data from patient charts, send staff to do health-risk assessments in patients’ homes and prod doctors to review potentially missed diagnoses. …

[Whistleblower] Ross recalls her managers lit up when they realized how much money it might bring in. Reviewing two years of data, DxID added thousands of potential diagnoses that increased Group Health’s revenue by $32 million, the U.S. alleged. But when Ross checked DxID’s work, she found that three-quarters of the diagnostic codes it submitted for payment lacked proper documentation and didn’t stand up to scrutiny, according to her complaint.

The plan got paid for one patient’s depression diagnosis even though a physician said it had resolved and the patient now had “an amazingly sunny disposition,” according to Ross’s complaint. It claimed another patient had kidney complications from diabetes even after a doctor had explicitly ruled that diagnosis out.

Comment:

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

This article highlights how even the most respected HMOs, like Group Health and Kaiser, fall prey to the temptations of increased revenue from highly suspect diagnostic upcoding practices. It’s terrific that whistleblowers and the federal government team up to catch and punish offenders, and perhaps discourage others.

However, the real money isn’t in the fraud, it’s in the legal upcoding that Medicare Advantage plans do and Medicare (CMS) fails to properly regulate. It’s well understood that MA plans have a much greater incentive than traditional Medicare to find and document diagnoses, because these added codes raise the capitation payments to MA whereas they don’t affect traditional Medicare reimbursements. CMS knows about this bias, and is permitted to adjust the payment levels to counteract it. But they put a cap on the size of the adjustment, even as upcoding grows rapidly in magnitude. The difference between upcoding and the allowable adjustment represents pure profit for MA plans.

The amounts at risk are staggering. CMS estimates $100 billion so far. Rick Kronick, a prominent health policy researcher, looks at trends and estimates a far greater toll in years to come. In a Nov 2021 article on the impact of sharply rising Medicare Advantage coding intensity he estimated that “total Medicare payments to MA will be $600 billion higher over the 2023-2031 period than … if the coding intensity adjustment were set [accurately] … $85 billion will be paid by beneficiaries in higher Part B premiums, and $515 billion in higher net Medicare spending.”

That’s highway robbery (by the MA plans) and dereliction of duty (by CMS).

Risk adjustment is being massively gamed by private insurers. Time to change the game, to single payer.

http://healthjusticemonitor.org…

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

Major Insurers Are Scamming Billions from Medicare, Whistle-Blowers Say

Billing for illnesses that don’t exist, like prostate cancer in a woman.

By John Tozzi
Bloomberg, April 12, 2022

Teresa Ross had been raising objections at work for months when her bosses brought in a psychologist hoping to make her question her own sanity.

A longtime manager at a Seattle health plan called Group Health Cooperative, Ross had opposed changes to the way the company billed Medicare. With the help of a new vendor, the insurer identified new diagnoses for patients, bringing in millions of extra dollars from the government. Ross insisted much of it was fraud. She says she was cut out of meetings.

Then she was invited to one with the psychologist. He asked how she was feeling and revealed that a senior executive had sent him to discuss her objections.

“People aren’t seeing you as a team player,” she recalls him saying. “They’re concerned that you have a loud voice within the organization. And you’re objecting to this thing that’s making us lots of money and everybody’s happy.”

Ross felt blindsided and insulted. The visit made no difference.

Ross had already filed a sealed whistleblower suit against the company, which later merged with Kaiser Permanente in 2017. After years of investigating, the Justice Department took up her case last year. Other whistleblowers came forward too, with allegations accusing Kaiser and some of its competitors of inflating how sick their members appeared to be to get higher payments from Medicare.

The industry vehemently contests the allegations and says that plans get paid appropriately for the risk they take on. But the disputed billing practices at the heart of Ross’s case have become central to the health-care business and, as baby boomers retire, to America’s fiscal future. Medicare covers 64 million people and will spend $900 billion this year, or 4% of U.S. gross domestic product. Almost half of people on Medicare now get their benefits through Medicare Advantage — private plans like the one Ross worked for, which get paid more for patients with more severe illnesses. That means a growing share of Medicare’s billions flows through arrangements susceptible to the kind of manipulation that Ross described.

Each year, the plans submit giant data files to Medicare with diagnostic codes meant to reflect their members’ illnesses. Those codes determine how much they get paid. A federal watchdog warned in March that coding differences brought Medicare Advantage plans $12 billion in excess payments in 2020, compared to what traditional Medicare would have paid to cover the same population. The cumulative extra payments since 2007 will soon top $100 billion, according to the Medicare Payment Advisory Commission, or MedPAC.

Those payments mounted as American seniors flocked to the private version of Medicare. Enrollment in Medicare Advantage doubled in the last decade to more than 26 million people, on pace to cover a majority of Medicare beneficiaries.

Insurance companies have built billion-dollar businesses propelled by this growth. UnitedHealth Group Inc., Humana Inc., and CVS Health Corp.’s Aetna unit combined enroll more than half of Medicare Advantage members. Kaiser Permanente, with about 7% of the market, isn’t far behind, according to data from the Kaiser Family Foundation, a research group unaffiliated with the health plan.

The industry calls the program a win-win. Medicare Advantage caps members’ out-of-pocket costs and offers extra benefits like dental, vision and hearing coverage that traditional Medicare doesn’t. Private plans also send clinicians on house calls, deliver meals and offer rides to medical appointments, stitching together medical care with services intended to address members’ social needs.

The program’s growing popularity has made it politically powerful. Republicans extoll its private-sector innovation while Democrats know that enrollees are disproportionately low-income and people of color. An industry coalition recently touted a letter signed by 346 U.S. representatives — more than 80% of the House — urging the Biden administration to “provide a stable rate and policy environment” for the program. Soon after, Medicare proposed payment rates for 2023 that an analyst for Veda Partners called “surprisingly good news for industry.”

Yet rising Medicare Advantage enrollment has also prompted warnings about the cost. The program’s hospital trust fund is projected to be depleted in 2026. “Failure to stem the excess spending created by coding intensity further jeopardizes the Medicare program’s already challenging fiscal sustainability,” MedPAC wrote in a comment letter to Medicare officials in March.

The industry has billions at stake in how the payments are calculated. In February, UnitedHealth asked the Supreme Court to review a case it lost on appeal challenging a policy to make insurers return payments for unsupported diagnoses. The policy “imposes potentially billions of dollars in additional payment obligations” on plans and would destabilize the Medicare Advantage program, the company said in its petition. Letting the decision stand threatens to reduce benefits and increase costs for seniors in the program, UnitedHealth argued.

Official scrutiny is growing. The Department of Justice called policing Medicare Advantage an important priority on its anti-fraud agenda. The agency said in February that it pursued health plans that gamed the system “by submitting unsupported diagnosis codes to make their patients appear sicker than they actually were,” and cited Ross’s case as an example. Ross’s attorneys estimate the scope of such frauds reaches into the billions of dollars.

Ross filed her complaint against Group Health under seal a decade ago, and it remained a secret for seven years. With the aid of other whistleblowers, the Justice Department has also sued industry giants including UnitedHealth, Anthem Inc. and Cigna Corp. over similar allegations in recent years. The companies are fighting the cases.

Now it’s up to the courts to decide which practices are legitimate and which constitute fraud. Ross remains shaken by her experience. Coming forward wasn’t easy, she said. “The easy thing would’ve been to sit down and just let it happen.”

Ross, 57, grew up outside Seattle, a math whiz in a family that kept busy with music lessons and school activities. Her father had a heart attack while she was in high school, and she spent a lot of time at the hospital, pressing his doctors for information. That early exposure coupled with her mathematical acumen led Ross into a career in an obscure corner of the health-care industry. In 1998, she arrived at a nonprofit insurer called Group Health Cooperative to lead a division building statistical models of patient risk.

In the 2000s, these models became central to the growing Medicare Advantage industry. Money hinged on the illnesses that plans documented for their members. Traditional Medicare pays doctors and hospitals directly for each test or service. In Medicare Advantage, health plans get a fixed payment from the government for each member they take on. The program will spend on average about $14,000 per enrollee this year. Through a process called risk adjustment, added diagnoses typically bump payments by $1,000 to $5,000, sometimes even $10,000, according to MedPAC. It’s meant to compensate insurers for taking on sicker patients and discourage them from cherry-picking healthy people.

Ross said she and Group Health originally embraced the system as a way to identify patients who needed care but weren’t getting it. “It’s not just digging for dollars,” she said. “It’s improving care.”

Her whistleblower suit and the Justice Department complaint that followed describe a growing pressure within the company to engineer higher risk scores for greater payments. She rebuffed one vendor called Leprechaun LLC hired in 2008 that wanted to submit claims “based on documentation that was clearly inadequate,” according to Ross’s complaint.

By 2011, Group Health’s finances deteriorated, and it was facing downgrades from credit raters. That fall, Group Health’s chief executive officer met a counterpart from a Buffalo plan called Independent Health, which had just formed a new subsidiary focused on risk adjustment called DxID, according to Ross’s complaint. In an early pitch, DxID CEO Betsy Gaffney told one of Ross’s colleagues that Group Health’s internal approach to risk-adjustment “is really putting you back financially,” according to the Justice Department complaint. “I get what the purpose of the policies are theoretically, and even kind of agree philosophically, but it is very restrictive,” she wrote in a November 2011 email.

Group Health hired DxID the next month on a contingency basis. The vendor would keep 20% of any new revenue it brought in from combing old patient charts to uncover missed diagnoses. Gaffney proposed new ways to identify patients who suffered from illnesses like chronic kidney disease or low oxygen levels, a condition called hypoxia, according to the Justice Department complaint.

Ross recalls her managers lit up when they realized how much money it might bring in. Reviewing two years of data, DxID added thousands of potential diagnoses that increased Group Health’s revenue by $32 million, the U.S. alleged. But when Ross checked DxID’s work, she found that three-quarters of the diagnostic codes it submitted for payment lacked proper documentation and didn’t stand up to scrutiny, according to her complaint.

DxID would pull illnesses from the “problem list” doctors maintained in electronic medical records, a section of the chart that sometimes contained old or resolved conditions, Ross said. The company also used lab tests or other orders as proxies to infer diagnoses, even when clinicians had not documented the illnesses. For example, patients getting supplemental oxygen were assumed to have hypoxia, even though oxygen can be prescribed for less serious problems like sleep apnea, the complaint says. Later DxID would send physicians “addendum” forms to update charts with suggested diagnoses, paying them $25 to fill them out, the U.S. alleged.

This approach produced some unlikely results. One patient’s depression was supposedly documented during a visit to an ophthalmologist, according to Ross’s complaint. In another case, when Gaffney was working for Independent Health, a woman was coded for prostate cancer, because “when a married couple has any disease, both were assigned to that disease,” she wrote in an email, according to the Justice Department complaint.

As Ross and her colleagues reviewed the submissions, they found DxID was adding diagnoses that doctors hadn’t made. “Coders are not allowed to diagnose anything,” Ross said. “That’s for doctors.”

Despite Ross’s protests, Group Health adopted most of the coding policies DxID proposed, Ross and the Justice Department allege. Her managers spurned her, she said, and eventually brought in the psychologist. Ross’s attorney, Mary Inman, a partner at whistleblower law firm Constantine Cannon, said Ross’s experience fits a pattern of tactics used to isolate corporate dissenters. “This is where you get the whistleblower to start to doubt herself,” Inman said. “That’s part of the corporate playbook that we see in these cases.”

Ross wasn’t dissuaded. In April 2012, after 14 years in a job she loved, she filed her complaint in federal court for the Western District of New York, where DxID was based. “The company that I had known to be ethical all of a sudden wasn’t,” she said. “They didn’t care about whether or not it was compliant. At least in my eyes, they were more concerned about what Betsy Gaffney was hanging out in front of them, which was millions and millions of dollars.”

Attorneys for Gaffney didn’t respond to multiple requests for comment. In a statement to the Buffalo News last year, they said she was “unfortunate victim of an ancient lawsuit premised on inaccurate allegations.” In legal filings seeking to dismiss the case, the defendants characterized the dispute as “good faith disagreements over objectively ambiguous coding criteria” and said that the allegations from Ross and the Department of Justice don’t meet the standards of a False Claims Act claim.

Whistleblowers file their initial complaints under seal to give the government time to investigate and decide whether to proceed. In Ross’s case, it lasted years. She left Group Health the year after she filed her complaint and moved on to other jobs while her case sat sealed on the docket.

Mostly unknown to Ross, other whistleblowers were coming forward with similar accounts at other companies, and federal investigators were building cases of their own. Both targeted some of the largest companies in the industry, which increasingly relied on Medicare Advantage as a source of profitable growth.

In 2017, the Justice Department intervened in a case against UnitedHealth, the largest Medicare Advantage provider. It sued Anthem in 2020. A whistleblower suit against Cigna was also unsealed that year. The companies are fighting the cases and have disputed allegations of wrongdoing. CVS Health and Humana have also both disclosed investigations into their risk adjustment practices and said they’re cooperating with the probes. UnitedHealth and CVS declined to comment for this story. Representatives for Anthem, Cigna and Humana didn’t respond to requests for comment. The Department of Justice declined to comment.

In 2017, Group Health was acquired by Kaiser Permanente, the giant California-based HMO. Ross’s own suit was unsealed in 2019, when the U.S. initially said it would not intervene but would keep investigating.

Kaiser Permanente’s Washington state subsidiary denied Ross’s allegations. Without admitting liability, the health plan resolved the lawsuit in 2020 in a settlement for $6.3 million — about one-fifth of the revenue increase Ross attributed to the practices in two years of its engagement with DxID. Ross was awarded $1.5 million, with the rest recovered by the government.

Kaiser Permanente spokesman Marc Brown said in an email that Group Health “submitted its data in good faith and in reliance on recommendations by DxID, its contracted risk adjustment vendor, which purported to be an expert in this area.”

DxID ceased operations last summer. But the U.S. attorney in the Western District of New York is pursuing the civil fraud claims Ross initiated against the vendor, its parent company Independent Health, and Gaffney as an individual defendant.

Independent Health and DxID deny wrongdoing and have moved to dismiss the lawsuit. “We believe the coding policies being challenged here were lawful and proper and all parties were paid appropriately,” Independent Health said in a statement. “Independent Health and DxID diligently navigate complex and vague coding criteria to ensure that all diagnosis and billing codes properly reflect our members’ medical conditions and are supported with documentation in the members’ medical records.” The company also said its plans received high ratings from Medicare.

Last summer, the Department of Justice intervened in six other cases against Kaiser Permanente filed by separate whistleblowers alleging that it defrauded Medicare through inflated risk codes. The health system says it will fight the suits and defended its audit record with Medicare. “Our policies and practices represent well-reasoned and good-faith interpretations of sometimes vague and incomplete guidance,” Kaiser Permanente said. The company declined interview requests.

The cases could take years to resolve. Ross, who struggled initially with her decision to come forward, has been heartened by the number of counterparts across the industry who raised similar concerns. “It took a long time for the government to really understand what was happening to them in this space,” she said.

https://www.bloomberg.com…

US Physician EHR Burden = Less Clinical Focus, More Burnout

Summary: The electronic health record is now ubiquitous. Doctors complain about its time demands and its emphasis on billing. This review quantifies that burden – more than 4 hours per day, far higher than in countries with simpler insurance.

How much time do physicians spend in the EHR?, KevinMD, April 10, 2022, by Thrisha Gogineni, James G. Kahn, Sigal Maya

Doctors often find the Electronic Health Record (EHR) time-consuming and annoying. … We assembled evidence on hours dedicated to the EHR each day by physicians. The result is impressive – 4.5 hours.

Ninety percent of office-based physicians in the US use an EHR system. However, many report negative experiences. Two recent studies found that physician EHR effort lowers clinical focus and contributes to burnout. EHRs are often described as having poor usability and being unintuitive and inefficient, detracting from clinical focus and sometimes even leading to patient harm.These systems also decrease collaboration and communication between doctors and nurses.

… To estimate the magnitude of EHR burden in the U.S. and potential savings with streamlined EHR function, we collated existing published evidence. …

The figure summarizes what we found. Median daily physician EHR time ranged from 3.5 to six hours with the observation, log file, and web tracking methods. … The time burden of the EHR in US was significantly higher than in other countries where reported daily EHR time was one hour.

This is a striking amount of time.

Greater demands in the U.S. for billing and regulation related documentation contribute to the excess time burden of EHR systems compared with other countries. …

Only half of a doctor’s day remains for direct clinical interactions with patients.

The essential lesson from this EHR evidence is that the time burden it imposes on physicians is substantial in the US, occupying hours that could otherwise be spent building truly meaningful relationships with patients (not “meaningful use” metrics!) and providing quality care.

Comment:

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

Doctors are forced to use the electronic health record, including entry of large amounts of clinically-irrelevant data, especially billing-related details about procedures and overly precise diagnostic codes. This degrades the clinical experience for doctor and patient alike.

This study (full disclosure: I’m an author) assembles evidence on the time burden. It is indeed large.

Although the EHR can improve access to medical information, it is a data-hungry beast that exacts a huge toll as measured in hours, clinical focus, communication quality, and quite likely clinical outcomes.

Single payer would permit us to streamline the EHR to focus on clinically relevant information, as in other wealthy countries.

(P.S. a podcast on this is coming, I’ll let you know)

http://healthjusticemonitor.org…

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

US Women of Reproductive Age Hurt by Insurance Barriers

Summary: “Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States. U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.” This says it all.

Health and Health Care for Women of Reproductive Age, The Commonwealth Fund, April 6, 2022, by Munira Z. Gunja et al

The maternal mortality crisis in the United States has been well documented: U.S. women have the highest rate of maternal deaths among high-income countries, while Black women are nearly three times more likely to die from pregnancy-related complications than white women are. But maternal deaths and complications may be a bellwether for the U.S.’s wider failures with respect to women’s health and health care.

Among women of reproductive age in high-income countries, rates of death from avoidable causes, including pregnancy-related complications, are highest in the United States.

U.S. women of reproductive age are significantly more likely to have problems paying their medical bills or to skip or delay needed care because of costs.

U.S. women of reproductive age have among the highest rates of multiple chronic conditions and the highest rate of mental health needs.

High health care costs are significant burdens for many U.S. households, even those covered by health insurance. Over one-quarter of women of reproductive age in the U.S. and Switzerland spend USD 2,000 or more in out-of-pocket medical costs, as compared with less than 5 percent of women in the U.K., France, and Netherlands.

Half of women of reproductive age in the U.S. reported skipping or delaying needed care because of costs. U.S. survey respondents were significantly more likely to report skipping care than respondents in all other countries. In the Netherlands, only 12 percent of women said they had forgone care for cost reasons. America’s outlier status on this measure likely stems from the large number of women who lack health insurance — 10 million — as well as the high copayments, coinsurance, and deductibles that many U.S. women enrolled in commercial health plans face when seeking care.

Compared to their counterparts in the other 10 countries, women of reproductive age in the U.S. were significantly more likely to report one or more medical bill problems, with over half saying they had experienced one or more. Only one in 10 women in the U.K., which provides free care to all residents through the country’s National Health Service, reported a medical bill problem.

When looking at all women, we found that those in the U.S. have the highest rate of avoidable deaths: nearly 200 in 100,000 deaths could have been prevented or treated with the right care provided at the right time.

Research shows that investing in women’s health results in a healthier overall population, healthier future generations, and greater social and economic benefits. Yet the U.S. remains the only wealthy country without universal health care, leaving about 10 million women without insurance.

Comment:

By Don McCanne, M.D.

How is the United States doing in providing adequate health care for its residents? Let’s just look at women of reproductive age – a group that plays such an important role in family and community life and should not be afflicted by medical risks more characteristic of older age.

Compared to other wealthy nations that spend less on health care than us, our record is miserable. Not only do our insurance programs leave many unacceptable gaps in coverage, we leave ten million women with no insurance coverage at all, thus potentially unnecessarily exposed to physical and financial suffering and even death. We are already spending the funds that could prevent this, but we are spending them on the wrong health care financing system – a highly dysfunctional, fragmented system designed to benefit venture capitalists and private equity investors, with insurance and much patient care being primarily a tool to enable wealth accumulation.

We are spending enough money to do it right, but it appears that our health care infrastructure is now so distorted by capital interests that even single payer Medicare for All may not be enough to ensure adequate health care for all. Maybe all of us, as communities, need to play a greater role. For those who missed it, several HJM contributors last week published an article in The Nation how communities, not corporations, should own our most vital health care assets.

With public financing and community control, women of reproductive age would no longer have to worry about their own health care access and affordability, and also would no longer have to worry about health care for their loved ones, or for everyone else.

Maybe women are best positioned to lead the march toward health care justice for all.

http://healthjusticemonitor.org…

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Big Insurer Explosive Growth & Profits Since ACA Passage

Summary: An excellent review of 12-year financial trends for the largest six insurers reveals: a) skyrocketing revenue and profits, b) based mainly on growth in the public insurance sector, and c) acquisition of pharmacy benefit plans. Half of Americans are in their plans.

A decade-long look at how Big Insurance profiteers American taxpayers and the sick, Wendell Potter NOW, April 4, 2022

Those six companies–Anthem, Centene, Cigna, CVS/Aetna, Humana, and UnitedHealth–are massively bigger today than they were 12 years ago [when the ACA was passed] as a result of numerous mergers and acquisitions and a new love interest: the government. In 2010, the companies took in a combined total of $245.2 billion dollars in revenue. Last year, that number had more than quadrupled to $1.1 trillion. …

Two of those companies–United and CVS/Aetna–have grown so fast they have leapfrogged into the top five of the Fortune 500 of America’s biggest companies. Only Walmart, Amazon and Apple took in more money last year than those two companies. (Cigna, the third largest in terms of revenue and my former employer, is now the 13th largest on the Fortune list.)

The big six insurers’ profits have soared along with their revenues. Last year they made $60.7 billion in profits collectively, compared to $16.9 billion in 2010. …

Relatively little of the six companies’ growth in health plan revenues and profits has come from private paying customers. By far most of the money they now collect to administer health plans comes from us as taxpayers. That’s because all of the companies have shifted their focus away from the private sector and toward various government-funded programs: Medicare, Medicaid, federal employees and the military. …

In 2010, 16.9 million Americans were enrolled in the Medicare Advantage, Medicare supplement and Medicaid plans operated by the big six. In 2021, that number had increased by 46 million–373%–to 63 million. …

Thanks to the many mergers and acquisitions since then, one of every two of us are now enrolled in one of their health plans. (And 31.1 million of us remain uninsured.) …

AND THEN THERE IS …

The Big Three of the Big Six make more money “managing” Americans’ prescription medications than by administering our health insurance plans. Aetna supersized itself when it merged with CVS, which operates the country’s largest pharmacy benefit management [PBM] company, Caremark, in 2017. Cigna bulked up the next year when it merged with Express Scripts, the second largest PBM. And United’s fastest growing and most profitable division is Optum, which encompasses the country’s third largest PBM. Together, CVS, Cigna, and United control nearly 80% of the national PBM market. At all three companies, the PBMs now generate more profits than their health plan businesses.

Those three companies are also far bigger than the biggest company that actually makes prescription medications. Johnson & Johnson, the biggest U.S. drug company, ranks a distant 36 on the Fortune 500. To put that in perspective, J&J was #33 on the Fortune list in 2010. Cigna, which is now #13 was #129 in 2010.

Comment:

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

The Affordable Care Act will strengthen the hand of private insurers, single payer advocates said in 2010. Oh how I wish we’d been wrong.

Wendell Potter’s review highlights just how right we were. Half of us are enrolled in plans (both private and public) run by the top six insurers, with $1.1 trillion in annual revenues and $61 billion in profits. (Lest you think, oh, that’s not such a big profit margin, consider that the rate of return on real investment is 6 to 9 times higher.)

Most of the gains are for publicly funded programs, primarily Medicare Advantage and Medicaid Managed Care.

They’ve even taken over pharmacy benefit management companies (PBMs), which specialize in extracting more profits from health care.

All in all, a dismal state of affairs. Profits grow exponentially, while access to care and health outcomes plummet. Shareholders gain and beneficiaries lose.

Time for disintermediation. Seriously.

http://healthjusticemonitor.org…

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

Nurse Conviction for Fatal Error vs System Harm

Summary: A nurse mistakenly gives an incorrect drug that kills a patient, and is convicted of homicide. Our system kills up to 100,000 a year due to un- and under-insurance, and nobody is indicted. Where is the justice and sense of proportion? Our inaction is outrageous.

Why Nurses Are Raging and Quitting After the RaDonda Vaught Verdict, KHN (Kaiser Health News), April 5, 2022, by Brett Kelman and Hannah Norman

Vaught, who worked at Vanderbilt University Medical Center in Nashville, was convicted in the death of Charlene Murphey, a 75-year-old patient who died from a drug mix-up in 2017. Murphey was prescribed a dose of a sedative, Versed, but Vaught accidentally withdrew a powerful paralyzer, vecuronium, from an automated medication-dispensing cabinet and administered it to the patient. …

Vaught was acquitted of reckless homicide but convicted of a lesser charge, criminally negligent homicide, and gross neglect of an impaired adult.

Comment:

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

A nurse in a university hospital was convicted of unintentionally killing a patient due to a medication error. She’ll likely get 8 years in prison.

Yet those who defend our dysfunctional health insurance system and extract tens of billions in profits by restricting access to care are causing 100,000 excess deaths per year. Do they know of these horrendous effects? They must; it’s plain to see in the stories and research (eg, here and here).

Where is justice? Proportionality? Common sense? Humanity?

I’m sick about our indifference to large-scale systematic harm. We punish one nurse for her inadvertent, if tragic, error. We protect and enable those who cause deaths on a massive scale.

http://healthjusticemonitor.org…

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

US Healthcare Reforms: What’s worked, and what we can try next

‘Apartheid’ Health Care? Why Medicaid Isn’t Cutting It for America’s Poor

By Brenda Gazzar
Code Wack Podcast, April 4, 2022

Why should people who have great health insurance care about people who don’t? Listen as guest Dr. Paul Y. Song, radiation oncologist and president of Physicians for a National Health Program – California, and host Brenda Gazzar, discuss the roots of America’s unequal healthcare system. Why did the Lyndon B. Johnson Administration develop two different public insurance programs – Medicare for retirees – and Medicaid for low-income people? How is that decision still impacting American communities over 50 years later? What can we do now that would help?

Transcript

Dispatcher: 911, what’s your emergency?

Caller: America’s healthcare system is broken and people are dying!

(ambulance siren)

Welcome to Code WACK!, where we shine a light on our callous healthcare system, how it hurts us and what we can do about it. I’m your host Brenda Gazzar. This time on Code WACK! What are inequities in American health care and why should everyone – even those with great health insurance – be concerned about them? The truth is they can have far-reaching consequences for us all — impacting public health, creating conditions for the spread of disease and even hindering economic productivity. We recently spoke to Dr. Paul Song, president of Physicians for a National Health Program-California, about how the COVID pandemic highlighted these longstanding inequalities and what the Biden administration can do about them.

Welcome back to Code WACK!, Dr. Song!

Q: We’ve talked a lot about inequities in health care. How do these inequities affect people of color specifically?

Song: Unfortunately, with regard to our healthcare system, the majority of disadvantaged communities of color are in the Medi-Cal system – very few work in jobs that provide real healthcare benefits. If you look at people who work at Walmart or some of those other stores, they don’t really get health insurance. So they’re asked to then get their health care through the government, which is through Medi-Cal, or many times through a subsidy, through the exchange, for which many of them can’t afford. And you know unfortunately we saw it again exposed during COVID is that when you saw the disproportionate amount of deaths among communities of color compared to white communities or more affluent communities, it really was a reflection of the long lack of health care that these people have had, meaning many of them had uncontrolled diabetes or high blood pressure that was uncontrolled. So when they got COVID, they were more likely to succumb to its effects.

At the same time, some of them, particularly frontline workers who were cleaning hotels or working grocery stores or in the food service industry or construction, many of them didn’t have health care and yet when they got sick, they couldn’t afford to go get tested. They couldn’t afford to go to the emergency room. They subsequently lived in multi-generational homes. They passed this on to all of the relatives in their houses and, you know, unfortunately it was very detrimental to communities of color disproportionately compared to everyone else.

Q: Right. And this is something that we’ve seen even before COVID, correct? COVID just kind of brought it to light even more.

Song: Correct and COVID just really did expose so much that’s broken and then you actually had hospitals in poorer communities that actually had to ration care because one, when you have a hospital like Martin Luther King Hospital, 75% of their revenue comes from Medi-Cal or uninsured compared to a hospital like Cedars (Sinai) or UCLA (Medical Center), where it’s such a small fraction. When you are getting reimbursed so little, you don’t have the luxury to go invest in additional ICU beds or ventilators or respiratory therapists. You’re basically scraping by just to serve your community. So when you get overwhelmed with people that are sick and you don’t have enough of those things that are required to really adequately address the problem, you’re going to have more death and, and that’s what we saw as well.

Q: Right. Great. Thank you. The last time we talked about the three major sources of health insurance and the obvious and not so obvious inequities inherent to each. Let’s talk about solutions. Instead of addressing inequities with more market reforms, what do you think is the first step the Biden administration should take toward promoting health equity in our country?

Song: Wow, it’s a complicated question, but for me, I think the answer’s quite simple. One is I think, due to the political climate, I don’t think we’re anywhere close to getting a federal Medicare for All, but I would like to see the Biden administration immediately sign a waiver allowing states to innovate and develop their own in-state single payer solutions. Next one I would do is instead of keeping Medi-Cal as is, I would immediately put all those enrollees on Medi-Cal into our Medicare system and just further make Medicare the de facto fallback insurance for everyone who needs it, whether it be seniors or the really poor. And so if you had between the seniors and then number of people on Medi-Cal, if you’ve just rolled that into one and gave everyone the same benefits as the Medicare beneficiaries, rather than Medicaid, I would feel like that would be significant, a significant starter until we got to a full federal single-payer Medicare for All system.

Q: Great, and that would allow them to be seen by doctors more quickly. So like you said, they wouldn’t have to wait a year before they got treated for cancer?

Song: I think it would do a lot. It would help lower income communities and their hospitals get much better reimbursement because now you’d be reimbursing at Medicare rates versus Medi-Cal or Medicaid rates and then as a result, these hospitals could invest more in equipment, in building out ICUs, bringing in more staff. It would also incentivize more doctors in these communities to take care of patients and as a result, I think it would increase access to care versus the system we have right now.

Q: Is this an idea that was ever considered seriously by any administration?

Song: No. Again, I think if you go back to Medicaid, it was always meant to be a second class in some respects, subtle wink and a nod apartheid system, right, who are mostly the poor that would qualify for this. It was predominantly people of color back in the 60s when Lyndon Johnson, you know, proposed this instead of trying to make Medicare and Medicaid, all one, they had to have this separate system. I think that if you were able to roll all that into one, it would have a significant impact on lower income communities and it would greatly reduce the disparity in health care that exists right now and until we got to a full Medicare for All, then you could have those people who got coverage through their employer continue to do so. It wouldn’t take away the complexities of our healthcare system, which is part of the administrative waste and all of the shenanigans that go on. But at least it would elevate the healthcare level for those that are the most disadvantaged and particularly in communities of color to those of what our seniors would be getting.

(5-second stinger)

Thank you, Dr. Paul Song.

Do you have a personal story you’d like to share about our ‘wack’ healthcare system? Contact us through our website at heal-ca.org.

Find more Code WACK! episodes on ProgressiveVoices.com and on Nurse Talk Media. You can also subscribe to Code WACK! wherever you find your podcasts. This podcast is powered by HEAL California, uplifting the voices of those fighting for healthcare reform around the country. I’m Brenda Gazzar.

https://heal-ca.org…

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Full opening remarks from Jeffrey Sachs

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Transcript

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