PNHP

The Old, the Young and Medicare

The Old, the Young and Medicare

Letters
The New York Times, July 3, 2011

I disagree with Daniel Callahan. I think that the economist Robert B. Reich expressed it best: “Medicare isn’t the problem. It is the solution.”

We do not have to reduce benefits or raise the age of eligibility to save Medicare. We need to expand and improve it so we have Medicare for all. This is what many other industrialized nations have done. They bring high-quality medical care to all their citizens at half the cost of what we spend.

It’s a no-brainer. Expanding the pool of beneficiaries to include everyone and financing it with progressive taxes is the way to “save” Medicare. There is already a bill in Congress, H.R. 676, that accomplishes this. We need to pass it.

ELIZABETH R. ROSENTHAL
Larchmont, N.Y., June 29, 2011

The writer is a dermatologist.

http://www.nytimes.com/2011/07/03/opinion/sunday/l03dialogue.html?_r=1&pagewanted=1

ALERT: The private insurers are taking over!

Managed Care Enters The Exam Room As Insurers Buy Doctor Groups

By Christopher Weaver
Kaiser Health News/Washington Post, July 1, 2011

Even if UnitedHealth Group isn’t your insurance company, there’s a good chance it touches you in some way. The $100 billion behemoth sells technology to hospitals and other insurers, distributes drugs, manages clinical trials and offers continuing medical education, among other things, through the growing web of firms it owns.

Now, that touch could get a lot more personal.  United’s health services wing is quietly taking control of doctors who treat patients covered by United plans in several areas of the country — buying medical groups and launching physician management companies, for example.

It’s the latest sign that the barrier between companies that provide health coverage and those that actually provide care to patients is crumbling. Other large insurers, including Humana and WellPoint, have announced deals involving doctors in recent months, part of a strategy to curb rising health costs that could cut into profits and to weather new challenges to their business arising from the federal health law. But United is the biggest insurer by revenue, making the trend much more significant.

Many patients insured by these companies are going to see much tighter management of their care.

“Health care costs are still going to rise,” said Wayne DeVeydt, chief financial officer of WellPoint, which entered the business of running clinics in June with the announcement that it would acquire CareMore, a health plan operator based near Los Angeles that owns 26 clinics. “But the only way to stem those costs in the long term is to manage care on the front end.”

That means enlisting doctors. Their orders drive most health care spending, including the wasteful share: treating heart patients with expensive stents when cheaper drugs might work, or overusing high-tech imaging devices, for example. By managing doctors directly, insurers believe they can reshape the practice of medicine – and protect their profits.

For instance, CIGNA, another large insurer, saves 9 percent on patients treated by doctors in a Phoenix medical group it controls, said Stephanie Gorman, president of CIGNA Arizona. CIGNA has expanded the group over the last 18 months in response to the health law, and it now serves patients at 32 locations.

Insurance companies are pursuing doctors in response to increasing financial pressure. The health law cuts government spending on private Medicare plans that many insurers offer, imposes rules that could limit profits, and increases scrutiny of their rates. Adding to the pressure, the insurers’ customers are tired of rising prices.

Employers and other customers “are saying, I want more value for the dollars I spend in health care,” said Dawn Owens, chief executive officer of OptumHealth, United’s health services subsidiary. But, “there’s also a realization that the delivery system isn’t ready for that kind of change. That’s where we come in.”

The tools needed to control costs and improve care are things insurers have “invested in over the years,” she said. “The provider community doesn’t have those tools.”

Dr. Amir Bacchus, chief medical officer of HealthCare Partners of Nevada, a large physician group, said he learned about United’s plans in a phone call from a United recruiter. He was asked if he’d be interested in joining the company to manage 500 doctors at a network of clinics United planned to build around the country, one part of its physician strategy.

By adding physicians in some places, United “can definitely control the health system” in those areas, said Bacchus, who declined United’s overture. “It’s a threat for us,” he added. “They are going to compete directly with our business model.”

United’s OptumHealth subsidiary, meanwhile, is buying doctors’ groups, building management companies to organize physicians, fostering new partnerships with medical groups and hiring doctors at a group it already controls.

Insurers managed physician practices before, especially in the 1990s. But customers rejected those tightly managed plans. Some local plans, and larger insurers such as Kaiser Permanente, continue to employ practicing doctors. But the biggest national insurers shed such arrangements.

One reason the strategy makes sense now is that the health law could reward such arrangements. The law envisions so-called accountable care organizations, groups of doctors and hospitals that take responsibility for patients and the financial risk that comes with them. If they cut spending, they would keep some of the savings.

While hospitals are widely seen as the natural leaders of ACOs, United’s strategy positions it to lead the new systems, too, a company executive acknowledged.

Some observers watching the developments say the health law, which in part was sold as a way to rein in insurers, has had the opposite result, opening the door for the companies to take control of even more parts of the health system.

“There’s a gigantic Murphy’s law emerging here,” said Ian Morrison, a California-based health care consultant who does some work for United, as well as most of its competitors. “The very people who were the demons in all of this, that the public can’t stand” – managed-care firms – “are the big winners.”

http://www.kaiserhealthnews.org/Stories/2011/July/01/unitedhealth-insurers-buy-doctors-groups.aspx

In the push towards integrated health systems, hospitals have been consolidating within markets in order to gain leverage in the negotiation of insurance contracts. Physicians have been consolidating within medical groups, also giving them greater market leverage. Leading the way, virtually all metropolitan insurance markets are now highly concentrated. In this power play between the health care giants, who is winning and who is losing?

Although the Medicare Shared Savings version of accountable care organizations is not gaining much traction, the underlying concept of integrating physicians and hospitals is. We are witnessing a power play by physician groups that want to be the entry point for health care through primary care medical homes and integrated specialty services. Many of these medical groups are establishing associations with hospitals in order to be able to contract with insurers as providers of comprehensive health care services.

On the other hand, hospitals would like to be in control, so they are not only consolidating but they are also purchasing physician practices. Is it the hospitals or the physicians who are winning this game?

Think back on how health care reform played out. Hospitals and physicians meekly supported the process mostly out of fear that their lot would be much worse off if they weren’t there during the process. But who was placed in control, with representatives actually writing the Affordable Care Act? The insurance industry! Everyone will be required to purchase their products, Medicaid is being converted to managed care organizations, and Medicare Advantage private health plans have been expanding. The private insurers are being given control of much of our national health care spending.

Look what the insurers are doing with that control. In the full version of the article provided at the link above and in many other information resources, you will see that the insurers are very busy trying to buy up enough of the health care delivery system to gain control of the health care markets. They will not only be the money managers for health care, but they will replace the current owners of the health care delivery system. In the worst possible outcome imaginable, they will be the actual providers of our health care!

Karen Ignagni of Americas Health Insurance Plans stated repeatedly during the reform process that the measure must provide effective mechanisms of controlling costs. It doesn’t. But now that the insurers are gaining total control, they will be able to bring us cost containment, but on their terms. How? As the CFO of WellPoint states, by owning the delivery system, they will be able to “manage care at the front end.” They will use their own doctors to prevent “overuse” and “protect their profits.”

A single payer system would be designed to macromanage dollars but would leave micromanagement of health care to the physicians and their patients. Once the insurers become the owners, the insurers will move in as the micromanagers of health care. Patients not only lose choice of their health care providers, but they also lose choice of their health care services and products.

So between the hospitals and the physicians, who comes out the winners? Neither. It’s the insurers who win. You can argue about whether or not the hospitals and physicians would be losers (or rather how much they would lose), but the tragedy of all of this is that the real losers would be those for whom the health care system should be designed – the patients.

For those who support a single payer Medicare for all system and believe that it will only be a matter of time before we’re there, think about this. When we have enacted a single payer system, the government will then negotiate with the providers of health care for delivery of health care services. That will not be with the physicians nor the hospital administrators, but it will be with the owners of the health care delivery system – the private insurers!

Unless we can enlist an outraged public to fight this thing, we will not end up with a single payer health care nirvana for all, but a single payer health care inferno from hell. Never have we had a greater imperative to inform and activate the public than right now. Let’s do it!

Prof. Gerald Friedman on single payer

Universal Health Care: Can We Afford Anything Less?

By Gerald Friedman
Dollars and Sense, July/August 2011

America’s broken health-care system suffers from what appear to be two separate problems. From the right, a chorus warns of the dangers of rising costs; we on the left focus on the growing number of people going without health care because they lack adequate insurance. This division of labor allows the right to dismiss attempts to extend coverage while crying crocodile tears for the 40 million uninsured. But the division between problem of cost and the problem of coverage is misguided. It is founded on the assumption, common among neoclassical economists, that the current market system is efficient. Instead, however, the current system is inherently inefficient; it is the very source of the rising cost pressures. In fact, the only way we can control health-care costs and avoid fiscal and economic catastrophe is to establish a single-payer system with universal coverage.

In short, the question is not whether we can afford a single-payer health-insurance system that would provide adequate health care for all Americans. The real question is: can we afford anything else?

(Gerald Friedman is a professor of economics at the University of Massachusetts-Amherst.)

http://www.dollarsandsense.org/archives/2011/0711friedman.html

Comment:

By Don McCanne, MD

It is great to have on board another economist from the academic community who understands the imperative of the single payer model. We should be hearing more from Professor Gerald Friedman.

NOW reaffirms support for single-payer health reform

National Organization for Women

Press release, June 27, 2011

The National Organization for Women wrapped up its 45th National Conference in Tampa, Fla. on Sunday, June 26, setting NOW’s policy and agenda for the coming year and looking toward the 2012 elections and beyond. Topping NOW’s policy agenda are improved Social Security benefits for women and a “Medicare for All” single-payer health care system as the solution to our health and fiscal crisis, including supporting Sen. Bernie Sanders’ American Health Security Act of 2011 (S 915).

“Women need jobs, not cuts,” said NOW President Terry O’Neill. “We oppose any cuts to Medicare, Medicaid and any health benefits derived from the Social Security Act. And candidates who want women’s support need to stand with us in support of single-payer health care legislation on the state and federal levels.”

Celebrations erupted throughout the conference when the New York state senate passed the marriage equality bill by a 33-29 vote. “This was a historic moment,” said O’Neill, “New York is the largest state to recognize same-sex marriage and we want other states to follow suit quickly. I’m proud of NOW’s long support for LGBT rights and even prouder that the conference passed a resolution calling for stepped-up activism for marriage equality.”

Other resolutions passed on the final day of the conference included pressing for reproductive civil rights legislation, using Title IX action networks to help end sex discrimination in education, ensuring inclusion of women and girls with disabilities in the U.S. Department of State programming and more.

The conference presenters, speakers and honorees, who included influential women in politics, groundbreaking activists and leaders in the medical field, were inspiring and motivating to the hundreds of NOW leaders gathered in Tampa.

O’Neill concluded: “The energy of the women that filled the rooms made this year’s NOW conference one to remember. I’m thrilled by the success of our gathering, and re-energized to win women’s long struggle for equality.”

http://now.org/press/06-11/06-27.html

Universal Health Care: Can We Afford Anything Less?

Why only a single-payer system can solve America’s health-care mess.

By Gerald Friedman
Dollars and Sense, July 2011

America’s broken health-care system suffers from what appear to be two separate problems. From the right, a chorus warns of the dangers of rising costs; we on the left focus on the growing number of people going without health care because they lack adequate insurance. This division of labor allows the right to dismiss attempts to extend coverage while crying crocodile tears for the 40 million uninsured. But the division between problem of cost and the problem of coverage is misguided. It is founded on the assumption, common among neoclassical economists, that the current market system is efficient. Instead, however, the current system is inherently inefficient; it is the very source of the rising cost pressures. In fact, the only way we can control health-care costs and avoid fiscal and economic catastrophe is to establish a single-payer system with universal coverage.

The rising cost of health care threatens the U.S. economy. For decades, the cost of health insurance has been rising at over twice the general rate of inflation; the share of American income going to pay for health care has more than doubled since 1970 from 7% to 17%. By driving up costs for employees, retirees, the needy, the young, and the old, rising health-care costs have become a major problem for governments at every level. Health costs are squeezing public spending needed for education and infrastructure. Rising costs threaten all Americans by squeezing the income available for other activities. Indeed, if current trends continued, the entire economy would be absorbed by health care by the 2050s.

Conservatives argue that providing universal coverage would bring this fiscal Armageddon on even sooner by increasing the number of people receiving care. Following this logic, their policy has been to restrict access to health care by raising insurance deductibles, copayments, and cost sharing and by reducing access to insurance. Even before the Great Recession, growing numbers of American adults were uninsured or underinsured. Between 2003 and 2007, the share of non-elderly adults without adequate health insurance rose from 35% to 42%, reaching 75 million. This number has grown substantially since then, with the recession reducing employment and with the continued decline in employer-provided health insurance. Content to believe that our current health-care system is efficient, conservatives assume that costs would have risen more had these millions not lost access, and likewise believe that extending health-insurance coverage to tens of millions using a plan like the Affordable Care Act would drive up costs even further. Attacks on employee health insurance and on Medicare and Medicaid come from this same logic—the idea that the only way to control health-care costs is to reduce the number of people with access to health care. If we do not find a way to control costs by increasing access, there will be more proposals like that of Rep. Paul Ryan (R-Wisc.) and the Republicans in the House of Representatives to slash Medicaid and abolish Medicare.

The Problem of Cost in a Private, For-Profit Health Insurance System

If health insurance were like other commodities, like shoes or bow ties, then reducing access might lower costs by reducing demands on suppliers for time and materials. But health care is different because so much of the cost of providing it is in the administration of the payment system rather than in the actual work of doctors, nurses, and other providers, and because coordination and cooperation among different providers is essential for effective and efficient health care. It is not cost pressures on providers that are driving up health-care costs; instead, costs are rising because of what economists call transaction costs, the rising cost of administering and coordinating a system that is designed to reduce access.

The health-insurance and health-care markets are different from most other markets because private companies selling insurance do not want to sell to everyone, but only to those unlikely to need care (and, therefore, most likely to drop coverage if prices rise). As much as 70% of the “losses” suffered by health-insurance providers—that is, the money they pay out in claims—goes to as few as 10% of their subscribers. This creates a powerful incentive for companies to screen subscribers, to identify those likely to submit claims, and to harass them so that they will drop their coverage and go elsewhere. The collection of insurance-related information has become a major source of waste in the American economy because it is not organized to improve patient care but to harass and to drive away needy subscribers and their health-care providers. Because driving away the sick is so profitable for health insurers, they are doing it more and more, creating the enormous bureaucratic waste that characterizes the process of billing and insurance handling. Rising by over 10% a year for the past 25 years, health insurers’ administrative costs are among the fastest-growing in the U.S. health-care sector. Doctors in private practice now spend as much as 25% of their revenue on administration, nearly $70,000 per physician for billing and insurance costs.

For-profit health insurance also creates waste by discouraging people from receiving preventive care and by driving the sick into more expensive care settings. Almost a third of Americans with “adequate” health insurance go without care every year due to costs, and the proportion going without care rises to over half of those with “inadequate” insurance and over two-thirds for those without insurance. Nearly half of the uninsured have no regular source of care, and a third did not fill a prescription in the past year because of cost. All of this unutilized care might appear to save the system money. But it doesn’t. Reducing access does not reduce health-care expenditures when it makes people sicker and pushes them into hospitals and emergency rooms, which are the most expensive settings for health care and are often the least efficient because care provided in these settings rarely has continuity or follow-up.

Sources of Savings and Added Costs for a Hypothetical Massachusetts Single-Payer Health System

The great waste in our current private insurance system is an opportunity for policy because it makes it possible to economize on spending by replacing our current system with one providing universal access. I have estimated that in Massachusetts, a state with a relatively efficient health-insurance system, it would be possible to lower the cost of providing health care by nearly 16% even after providing coverage to everyone in the state currently without insurance (see Table 1). This could be done largely by reducing the cost of administering the private insurance system, with most of the savings coming within providers’ offices by reducing the costs of billing and processing insurance claims. This is a conservative estimate made for a state with a relatively efficient health-insurance system. In a report prepared for the state of Vermont, William Hsiao of the Harvard School of Public Health and MIT economist Jonathan Gruber estimate that shifting to a single-payer system could lead to savings of around 25% through reduced administrative cost and improved delivery of care. (They have also noted that administrative savings would be even larger if the entire country shifted to a single-payer system because this would save the cost of billing people with private, out-of-state insurance plans.) In Massachusetts, my conservative estimates suggests that as m
uch as $10 billion a year could be saved by shifting to a single-payer system.

Greater Increase in Cost for U.S. Health-Care System, 1971-2007

Single-Payer Systems Control Costs by Providing Better Care

Adoption of a single-payer health-insurance program with universal coverage could also save money and improve care by allowing better coordination of care among different providers and by providing a continuity of care that is not possible with competing insurance plans. A comparison of health care in the United States with health care in other countries shows how large these cost savings might be. When Canada first adopted its current health-care financing system in 1968, the health-care share of the national gross domestic product in the United States (7.1%) was nearly the same as in Canada (6.9%), and only a little higher than in other advanced economies. Since then, however, health care has become dramatically more expensive in the United States. In the United States, per capita health-care spending since 1971 has risen by over $6,900 compared with an increase of less than $3,600 in Canada and barely $3,200 elsewhere (see Table 2). Physician Steffie Woolhandler and others have shown how much of this discrepancy between the experience of the United States and Canada can be associated with the lower administrative costs of Canada’s single-payer system; she has found that administrative costs are nearly twice as high in the United States as in Canada—31% of costs versus 17%.

The United States is unique among advanced economies both for its reliance on private health insurance and for rapid inflation in health-care costs. Health-care costs have risen faster in the United States than in any other advanced economy: twice as fast as in Canada, France, Germany, Sweden, or the United Kingdom. We might accept higher and rapidly rising costs had Americans experienced better health outcomes. But using life expectancy at birth as a measure of general health, we have gone from a relatively healthy country to a relatively unhealthy one. Our gain in life expectancy since 1971 (5.4 years for women) is impressive except when put beside other advanced economies (where the average increase is 7.3 years).

The relatively slow increase in life expectancy in the United States highlights the gross inefficiency of our private health-care system. Had the United States increased life expectancy at the same dollar cost as in other countries, we would have saved nearly $4,500 per person. Or, put another way, had we increased life expectancy at the same rate as other countries, our spending increase since 1971 would have bought an extra 15 years of life expectancy, 10 years more than we have. The failure of American life expectancy to rise as fast as life expectancy elsewhere can be directly tied to the inequitable provision of health care through our private, for-profit health-insurance system. Increases in life expectancy since 1990 have been largely restricted to relatively affluent Americans with better health insurance. Since 1990, men in the top 50% of the income distribution have had a six-year increase in life expectancy at age 65 compared with an increase of only one year for men earning below the median.

Increase in Health-Care Expenditures per Capita Associated with an Increase of One Year in Female Life Expectancy, 1971-2007

Rising health-care costs reflect in part the greater costs of caring for an aging population with more chronic conditions. As such, the United States looks especially bad because our population is aging less quickly than that of other countries because of high rates of immigration, relatively higher fertility, and the slower increase in life expectancy in the United States. Countries also buy higher life expectancy by spending on health care; rising health expenditures have funded improvements in treatment that have contributed to rising life expectancy throughout the world. Female life expectancy at birth has increased by nearly nine years in Germany since 1971, by over eight years in France, by seven years in Canada and the United Kingdom, and by six years in Sweden. By contrast, the United States, where female life expectancy increased by a little over five years, has done relatively poorly despite increasing health-care expenditures that dwarf those of other countries. In other countries, increasing expenditures by about $500 per person is associated with an extra year of life expectancy. With our privatized health-insurance system, we need spending increases over twice as large to gain an extra year of life (see Figure 1).

Difference in Female Life Expectancy at Birth (in Years), U.S. Compared with Other Countries, 1971 and 2007

The international comparison also provides another perspective on any supposed trade-off between containing costs and expanding coverage. In countries other than the United States, almost all of the increase in health-care spending as a share of national income is due to better quality health care as measured by improvements in life expectancy (see Figure 2). The problem of rising health-care costs is almost unique to the United States, the only advanced industrialized country without universal coverage and without any effective national health plan.

In short, the question is not whether we can afford a single-payer health-insurance system that would provide adequate health care for all Americans. The real question is: can we afford anything else?

Gerald Friedman is a professor of economics at the University of Massachusetts-Amherst

Sources: Cathy Shoen, “How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007,” Health Affairs, June 10, 2008; “Insured but Poorly Protected: How Many Are Underinsured?  U. S. Adults Trends, 2003 to 2007,” Commonwealth Fund, June 10, 2008 (commonwealthfund.org); David Cutler and Dan Ly, “The (Paper) Work of Medicine: Understanding International Medical Costs,” Journal of Economic Perspectives, Spring 2011; Stephen M. Davidson, Still Broken: Understanding the U.S. Health Care System, Stanford Business Books, 2010; P Franks and C M Clancy, “Health insurance and mortality. Evidence from a national cohort,” The Journal of the American Medical Association, August 11, 1993; Allan Garber and Jonathan Skinner, “Is American Health Care Uniquely Inefficient?” Journal of Economic Perspectives, Fall 2008; Jonathan Gruber, “The Role of Consumer Co-payments for Health Care: Lessons from the RAND Health Insurance Experiment and Beyond,” Kaiser Family Foundation, October 2006 (kff.org); David Himmelstein and Steffie Woolhandler, “Administrative Waste in the U.S. Health Care System in 2003,” International Journal of Health Services, 2004; “The Uninsured: A Primer: Supplemental Data Tables,” Kaiser Family Foundation, December 2010; Karen Davis and Cathy Shoen, “Slowing the Growth of U.S. Health Care Expenditures: What are the Options?” Commonwealth Fund, January 2007 (commonwealthfund.org); “Accounting for the Cost of Health Care in the United States,” McKinsey Global Institute, January 2007 (mckinsey.com); “Investigation of Health Care Cost Trends and Cost Drivers,” Office of Massachusetts Attorney General Martha Coakley, January 29, 2010 (mass.gov);
 Trends in Mortality Differentials and Life Expectancy for Male Social Security-Covered Workers, by Average Relative Earnings by Hilary Waldron, Social Security Administration, October 2007; Richard G. Wilkinson, The Spirit Level, Bloomsbury Press, 2010; William Hsiao and Steven Kappel, “Act 128: Health System Reform Design.  Achieving Affordable Universal Health Care in Vermont,” January 21, 2011 (leg.state.vt.us); Steffie Woolhandler and Terry Campbell, “Cost of Health Care Administration in the United States and Canada,” New England Journal of Medicine, 2003.

http://www.dollarsandsense.org/archives/2011/0711friedman.html

Prof. Gerald Friedman on single payer

Universal Health Care: Can We Afford Anything Less?

By Gerald Friedman
Dollars and Sense, July/August 2011

America’s broken health-care system suffers from what appear to be two separate problems. From the right, a chorus warns of the dangers of rising costs; we on the left focus on the growing number of people going without health care because they lack adequate insurance. This division of labor allows the right to dismiss attempts to extend coverage while crying crocodile tears for the 40 million uninsured. But the division between problem of cost and the problem of coverage is misguided. It is founded on the assumption, common among neoclassical economists, that the current market system is efficient. Instead, however, the current system is inherently inefficient; it is the very source of the rising cost pressures. In fact, the only way we can control health-care costs and avoid fiscal and economic catastrophe is to establish a single-payer system with universal coverage.

In short, the question is not whether we can afford a single-payer health-insurance system that would provide adequate health care for all Americans. The real question is: can we afford anything else?

(Gerald Friedman is a professor of economics at the University of Massachusetts-Amherst.)

http://www.dollarsandsense.org/archives/2011/0711friedman.html

It is great to have on board another economist from the academic community who understands the imperative of the single payer model. We should be hearing more from Professor Gerald Friedman.

Health care for all is Christian and practical, physician says

By Kay Campbell
The Huntsville (Ala.) Times, June 29, 2011

HUNTSVILLE, Ala. — Truly selfish people, once they consider the facts, will support national health care for all for purely self-serving reasons, states Dr. Pippa Abston in her new book. But Christians especially should understand why it’s time the U.S., one of the wealthiest countries in the world, made sure our health care standards are increased.

Abston, a pediatrician who has been active with Physicians for a National Health Program, has written “Who is my neighbor? A Christian response to healthcare reform” to answer objections to government interference in the current patch-work system of health care coverage in the U.S.

The book is structured around lines from the parable of the Good Samaritan, the story told by Jesus in which a heathen foreigner shows by example how to care for someone in need. Using simply told, heart-wrenching illustrations from her own work, Abston walks through the experience of navigating today’s insurance maze from the doctor’s point of view. In non-exaggerated explanations, she clicks through all the arguments against “socialized” medicine, as detractors disparage it, showing why good medicine for all means better physical health for all, better health options for all, and better economic health for the country.

Abston is a skilled writer, so the book’s self-published pedigree shows only in the simple design and infrequent typo of the self-edited book. (Abston decided to self-publish to get the book into circulation fast.) The essay diagrams the inevitable need for a health care system based upon reason, rather than the bake sales that fund so much cancer treatment now.

We have to learn to see everyone as important, just as Jesus did, Abston writes.

“Absolutely refuse to un-see any person — ever,” she writes. “No matter who and no matter what. Whomever God sees, so must we.”

The book is available at Blurb.com. Abston blogs at “A Pediatrician’s Perspective on Healthcare Reform.”

http://blog.al.com/living-times/2011/06/healthcare_for_all_is_christia.html

New CDC numbers on uninsured

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2010

by Robin A. Cohen, Ph.D., Brian W. Ward, Ph.D., and Jeannine S. Schiller, M.P.H. Division of Health Interview Statistics, National Center for Health Statistics
Centers for Disease Control and Prevention, June 22, 2011

* In 2010, 48.6 million persons of all ages (16.0%) were uninsured at the time of interview, 60.3 million (19.8%) had been uninsured for at least part of the year prior to interview, and 35.7 million (11.7%) had been uninsured for more than a year at the time of interview.

* In 2010, the percentage of persons who were uninsured at the time of interview among the 20 largest states ranged from 4.0% in Massachusetts to 26.1% in Arizona.

* In 2010, the percentage of children under age 18 years who were uninsured at the time of interview was 7.8%.

* In 2010, among adults aged 19–25 years, 10 million (33.9%) were uninsured at the time of interview.

* Private coverage decreased among near poor adults aged 18–64 years, from 52.6% in 1997 to 34.7% in 2010. The uninsured rate (43.0%) was higher than the private coverage rate (34.7%) for this population.

* During 2010, 25.3% of persons under age 65 years with private health insurance at the time of interview were enrolled in a high deductible health plan (HDHP), including 7.7% who were enrolled in a consumer-directed health plan (CDHP). Almost 50% of persons with a private plan obtained by means other than through employment were enrolled in a HDHP.

http://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201106.htm

Comment: 

By Don McCanne, MD

To no surprise, the number of uninsured continues to increase. In the 2010 survey, over 60 million individuals were uninsured for at least part of the year. Private health insurance coverage continued to decline, whereas public coverage increased, especially for children. The gains in public coverage failed to offset the losses in private coverage. Young adults continue to have the lowest coverage rates of all.

Although there is much information in this 28 page report, let’s briefly look at two notable findings:

* For “near poor” adults under 65 (100-200% of federal poverty level), more were uninsured than were covered by private plans (43.0% vs. 34.7%).

* For those under 65 covered by private plans, 25.3% are now enrolled in a high-deductible health plan (HDHP). Only 7.7% also have a health savings account or equivalent (consumer-directed health plan – CDHP).

Enthusiasts for the Affordable Care Act (ACA) would likely claim that deficiencies such as these are precisely why ACA is so important. So what will ACA do for these individuals?

The near poor will be moved into Medicaid plans. Because that is a chronically underfunded program, there is already a lack of willing providers, especially amongst specialists (plus an across-the-board lack of primary care professionals). Infusing this large number of newly qualified beneficiaries into the Medicaid program will not only provide them a “ticket-without-a-show,” but it will also further impair access for those already enrolled because of a lack of capacity amongst the willing.

The current trend of moving Medicaid patients into managed care organizations is not a satisfactory solution because the only way these business organizations can remain viable is by further reducing spending on the patients, especially since they have even higher administrative costs. Although health care prices are high in the United States, that is not true of Medicaid. Prices have already been squeezed to their bottom limit and beyond. That means that these managed care organizations have only one way left to reduce spending – cut health care services.

What about those who have high-deductible health plans? We already know of the harm caused by these HDHPs. (As an example, see: https://pnhp.org/news/2010/november/high-deductible-health-plans-foster-bad-decisions-by-rich-and-poor). We are now witnessing the rapid shift of employer-sponsored plans to HDHPs, because the premiums are lower (since they shift costs to the pockets of individuals with health care needs). The individual health insurance market has seen an even greater shift towards HDHPs since more comprehensive plans are no longer affordable for the majority of us.

Will the state insurance exchanges provide relief? No. Most plans will have a low actuarial value which will automatically require high deductibles (since they will be required to cover a basic benefit package which cannot be pared down).

The point of all this is that those who say that the increase in the numbers of uninsured isn’t important because we will be taking care of that by covering them through ACA have missed the whole point that we have been trying to make. The goal is not simply to improve the count of nominally insured individuals. The goal is to remove financial barriers to health care – for everyone. An underfunded Medicaid program and a market of private plans with intolerable cost sharing are not going to do that.

Other nations have figured out how to do it – with far less money. Surely we have enough ingenuity in this nation to accomplish the same. Come to think of it, we don’t need ingenuity. The beneficial policies of other nations are not intellectual property. We can copy them.

Doctors aren't accepting new patients with private insurance either

By Aaron Carroll
The Incidental Economist, June 28, 2011

With so much press being made about doctors refusing patients with Medicare and Medicaid, it seems like public insurance is just a bad deal. Some of us, however, have been arguing that you’re only hearing part of the story. For instance, both Harold and Austin have argued that only looking at one large and broad private plan ignores the fact that many other private plans are much less robust and offer more limited access than BCBS. Others, like me, have argued that by focusing on specialists and adult docs, we miss the populations most often covered by these prorgams.

A new study just published in Archives of Internal Medicine gets at some of these problems:

Methods:

We performed an analysis of trends from 2005 through 2008 using data from the National Ambulatory Medical Care Survey (NAMCS). NAMCS is a nationally representative survey administered by the Centers for Disease Control’s National Center for Health Statistics. It contains information about physicians practicing in nonfederally funded, nonhospital–based offices throughout the United States, excluding those in anesthesiology, radiology, and pathology. Data on hospital associated practices were not available. NAMCS uses a complex sampling design with physician weighting so that national estimates of physician and practice characteristics can be reliably generated… The sample was restricted to physicians who accepted new patients (4632 physicians, 95.1% of the sample). Pediatricians and obstetricians (520 physicians) were excluded in the analysis of Medicare acceptance rates. We report weighted percentages of physicians who accepted new patients by insurance type and year…

What did the researchers do? They examined data from a representative sample pf physicians. Specifically, they looked at how often physicians accepted new patients by insurance type and year.

What did they find? The overall acceptance rate of new patients was pretty static from 2005-2008, going from 94.2% to 95.3%. The percentage of physicians accepting new Medicare patients dropped from 95.5% from 92.9% (about 2.5%). But here’s the thing. There was a bigger drop in physician acceptance of patients with private noncapitated insurance from 93.3% to 87.8% (about 5.5%). In fact, they found that over 90% of physicians accepted new Medicare patients. Reports of reimbursement rates driving away physicians may be more anecdotal than widespread.

So, yes, Medicare acceptance rates dropped, but private insurance acceptance rates dropped more overall. Interesting.

Using data in tables attached to the study, I also made some charts showing how new patient acceptance rates of physicians differed in the groups I’ve argued matter. Let’s start with primary care physicians:

What should we note here? First that the difference in the rates of acceptance of new patients with Medicare, private non-capitated patients, and self-pay patients are pretty similar. If you want to get detailed, however, the acceptance rate of private non-capitated patients went down more than the other two groups. Second, Medicaid acceptance rates were lower. They were comparable, however, to the acceptance rate of patients in private capitated plans. Also, not much changed from 2005-2008.

Here’s pediatricians:

Now obviously there’s no Medicare line, as these are kids. But notice the Medicaid line? Not much change overall from 2005-2008. Here’s the shocker, though. The acceptance of Medicaid is much closer to that of private non-capitated patients, and much better than that of private capitated plans. Acceptance rates of patients with those plans dropped off pretty severely between 2005 and 2008.

Finally, here’s Ob-Gyns:

Medicaid acceptance rates? Up from 2005 to 2008. Acceptance of all private plans? Down from 2005 to 2008. Moreover, Medicaid acceptance rates crush those of private capitated plans once again.

I’m not arguing that Medicaid and Medicare don’t under-reimburse, or that they don’t have significant issues. They do, and they do.

But the story you’ve been hearing is that (1) doctors are fleeing Medicare and Medicaid in droves and that (2) doctors much prefer private insurance to either of these programs. That’s not the whole story. Doctors, especially primary care docs, seem more likely to accept new patients with Medicare than with private capitated plans and likely many private non-capitated plans. Medicaid performs comparably to private capitated plans with primary care docs overall. But remember that Medicaid is primarily a plan for pregnant women and children. And ob-gyns and pediatricians are more likely to accept new patients with Medicaid than private capitated plans. And, while they don’t seem to be cutting back on Medicaid patients, they do seem to be accepting fewer patients with private plans overall.

That’s a much different story. It’s one worth investigating further.

http://theincidentaleconomist.com/wordpress/doctors-arent-accepting-new-patients-with-private-insurance-either/

Orszag – Medicare, not commercial insurers, has the clout

Orszag sees legislative gridlock ahead

By Melanie Evans
ModernHealthcare.com, June 28, 2011

Peter Orszag, former director of the Office of Management and Budget, speaking before health finance executives in Orlando, said an overhaul of U.S. healthcare payment to reward value cannot succeed without Medicare, yet policymakers face gridlock in what is a highly politicized environment.

Commercial insurers are too fragmented to change healthcare payments, but Medicare has the clout, he explained. Options under consideration to address the nation’s rising healthcare costs, which Orszag called the primary source of the U.S. fiscal woes, won’t accomplish much, Orszag said. Cuts to Medicare provider payments are “blunt” and “temporarily effective” but not a “long-term answer.” He dismissed rationing care as politically unviable. Proposals to increase household financial liability for healthcare are least effective among the most costly patients, which policy makers must address to slow spending, he said.

http://www.modernhealthcare.com/article/20110628/NEWS/306289975

Healthcare Financial Management Association
http://www.hfmaconference.org/2011/06/orszag-key-to-improving-quality-is-reducing-variation/

Comment: 

By Don McCanne, MD

According to Peter Orszag, “commercial insurers are too fragmented to change healthcare payments, but Medicare has the clout.” Though he didn’t expand on that with the obvious extrapolation, we can. Let’s get rid of the commercial insurers and improve and expand Medicare so that it covers everyone.

Orszag – Medicare, not commercial insurers, has the clout

Orszag sees legislative gridlock ahead

By Melanie Evans
ModernHealthcare.com, June 28, 2011

Peter Orszag, former director of the Office of Management and Budget, speaking before health finance executives in Orlando, said an overhaul of U.S. healthcare payment to reward value cannot succeed without Medicare, yet policymakers face gridlock in what is a highly politicized environment.

Commercial insurers are too fragmented to change healthcare payments, but Medicare has the clout, he explained. Options under consideration to address the nation’s rising healthcare costs, which Orszag called the primary source of the U.S. fiscal woes, won’t accomplish much, Orszag said. Cuts to Medicare provider payments are “blunt” and “temporarily effective” but not a “long-term answer.” He dismissed rationing care as politically unviable. Proposals to increase household financial liability for healthcare are least effective among the most costly patients, which policy makers must address to slow spending, he said.

http://www.modernhealthcare.com/article/20110628/NEWS/306289975

Healthcare Financial Management Association
http://www.hfmaconference.org/2011/06/orszag-key-to-improving-quality-is-reducing-variation/

According to Peter Orszag, “commercial insurers are too fragmented to change healthcare payments, but Medicare has the clout.” Though he didn’t expand on that with the obvious extrapolation, we can. Let’s get rid of the commercial insurers and improve and expand Medicare so that it covers everyone.

Declines in physician acceptance of Medicare less than private coverage

Declines in Physician Acceptance of Medicare and Private Coverage

By Tara F. Bishop, MD, MPH; Alex D. Federman, MD, MPH; Salomeh Keyhani, MD, MPH
Archives of Internal Medicine, June 27, 2011

A number of articles in the lay and medical press report a decline in the number of physicians who accept patients with Medicare; however, to our knowledge, recent trends in acceptance of different types of insurance have not been examined. Using data from a national survey of physicians, we examined trends in physician acceptance of different types of insurance and self-pay patients.

Results

The percentage of physicians accepting new patients did not vary significantly between 2005 and 2008, ranging from 94.2% to 95.3%. Physician acceptance of new Medicare patients dropped from 95.5% in 2005 to 92.9% in 2008 (P = .01). Physicians in private practice were largely responsible for the declining acceptance of Medicare patients as determined in stratified analyses (95.5% in 2005 vs 93.0% in 2008; P = .01) (eTable).

There was a more pronounced decline in physician acceptance of patients with private noncapitated insurance (93.3% in 2005 vs 87.8% in 2008; P < .001). A smaller percentage of adult primary care physicians accepted private noncapitated patients over the study period (97.3% in 2005 vs 89.9% in 2008; P < .001).

Rates of acceptance of new Medicaid and private capitated patients were lower than Medicare and private noncapitated insurance, but also showed a decline over the study period. Acceptance of self-paying patients was more than 96% in all years and did not change significantly over the study period.

While reports in the press highlight physicians’ dissatisfaction with Medicare, we found only a small decline in physician acceptance of Medicare patients between 2005 and 2008. In contrast, the decline in physician acceptance of noncapitated privately insured patients was more pronounced. Physicians continued to accept patients who were self-paying.

Although physician reimbursement under Medicare is often cited as the reason why physicians turn away Medicare patients, our findings that more than 90% of physicians continue to accept Medicare patients despite marginal increases in reimbursement suggest that anecdotal reports may be overstating access problems.

The observed decline in acceptance of private noncapitated insurance was unexpected and could be related to reimbursement but also to administrative burden. Acceptance rates of capitated insurance was lower and may reflect lower reimbursement in this model. Finally, the low and declining acceptance of new Medicaid patients is not surprising given the program’s historically poor reimbursement rate. Low rates of Medicaid acceptance may threaten access to care for the estimated 16 million Americans who will receive Medicaid coverage as a result of the Patient Protection and Affordable Care Act.

http://archinte.ama-assn.org/cgi/content/full/171/12/1117

eTable. Percentage of physicians accepting new patients by insurance type, practice type, and specialty, 2005-2008:
http://archinte.ama-assn.org/cgi/data/171/12/1117/DC1/1

Comment: 

By Don McCanne, MD

The good news in this report is that the often stated claim that physicians are dumping Medicare patients in favor of privately insured patients is not really true, at least as of 2008. Although there has been a small decline in the numbers of physicians accepting Medicare, well over 90 percent still do. Contrary to claims otherwise, the decline in the acceptance of privately insured patients was even greater.

Examining the breakdown in the eTable (link above) reveals some other interesting though not unexpected findings. With the exception of community health centers, close to one-third of physicians do not accept new Medicaid patients. Even more do not accept privately insured capitated patients (paid a flat amount per month per patient rather than fee for service). Over half of HMOs do not accept self-pay patients, though acceptance rates for these patients is very high in private practices and community health centers.

Although cash paying patients had the best access, this report does not cover the potentially catastrophic consequences of being uninsured or inadequately insured (e.g, high deductibles). Having adequate insurance is essential. The new lower actuarial value standards of private insurance make them a less desirable model for expanding coverage. Also the chronic underfunding of Medicaid makes it a poor choice.

Although Medicare remains popular and is widely accepted, it does need to be improved. Once we do that then it would be the ideal program to cover everyone. Acceptance rates would be virtually 100 percent.