PNHP

Medicare Advantage and Vertical Consolidation in Health Care

Medicare Advantage and Vertical Consolidation in Health Care

By Hayden Rooke-Ley
American Economic Liberties Project, April 30, 2024

A new wave of health care consolidation is underway. Health insurance and retail conglomerates are rapidly acquiring providers, from primary care practices and surgery centers to home-based and post-acute care. UnitedHealth Group (UnitedHealth), for example, is now the nation’s largest insurer and the largest employer of physicians. Humana is now the largest provider of “senior-based” primary care and in-home care. CVS Health, Walgreens, and Amazon, which have been aggressively consolidating the prescription drug supply chain, are now acquiring physician practices. And private equity investors—looking to consolidate industry segments and then sell to these conglomerates as an eventual exit—are accelerating these rollups.

With dominant market power, the new health care conglomerates can dictate which physicians patients can see, which medications are prescribed to them, and which insurance plans they enroll in. By acquiring medical practices, these corporate employers can shorten visit times, require more clinical coding and box-checking, and replace physicians with lower-cost clinicians. Meanwhile, by coordinating across lines of business, conglomerates like UnitedHealth can squeeze out independent practices and community pharmacies. They can also shuffle money between subsidiaries and use other financial tactics to skirt regulations and exploit payment loopholes, increasing health care costs.

This paper details the causes and costs of this new frontier of consolidation and offers a set of solutions to address it. In short, sweeping changes in health care financing policy are causing insurers and retailers to restructure as vertically integrated conglomerates. While technical, how the government pays providers and insurers fundamentally shapes the business strategies of health care companies. As the government continues to privatize Medicare and Medicaid, it is significantly overpaying insurance companies to administer benefits. With this excess capital, these insurers are acquiring providers, gaining control of key points in the delivery system that enable them to capture greater government payments and minimize spending on patient care. To take one prominent example, control over primary care clinicians allows these corporate owners to manipulate billing and coding practices to make patients appear sicker to the government, thereby increasing payments.

Part I of this paper explains how government policy over the last two decades has transformed health care financing. In an attempt to solve health care’s value problem— high spending and poor health outcomes—policymakers have steadily abandoned “fee- for-service” financing, in which medical providers are reimbursed for each service that a patient receives. Instead, public programs have increasingly adopted “capitation-based” financing. In this model, the government pays a fixed budget to a “risk-bearing entity”—an insurance company, hospital system, or group of physicians—to manage the total health care costs for a patient. The risk-bearing entity turns a profit if it keeps costs below the established budget, which is adjusted based on the perceived sickness of the population and metrics of care quality. In this paper, this policy agenda and its underlying ideological framework are referred to as health policy’s “Capitation Consensus.”

Medicare Advantage, the privatized version of Medicare that now covers more than half of Medicare beneficiaries, is the most prominent example of the Capitation Consensus. But this financing approach has spread across public health care programs: nearly all of Medicaid has moved to capitation-based financing, and Medicare’s prescription drug benefit, Part D, operates entirely on capitation. In the last decade, traditional Medicare— the historically fee-for-service model of Medicare—has been integrating versions of capitation through accountable care organizations and other value-based care models. Despite high hopes, the shift to capitation has yet to deliver on its primary objective of cost reduction. Most concerning is that Medicare Advantage now costs taxpayers anywhere from $75 billion to $140 billion annually in over-subsidization relative to traditional Medicare.

Part II of this paper explains how the Capitation Consensus is driving vertical consolidation. With excess capitation payments, Medicare Advantage insurance conglomerates are plunging capital into provider acquisitions, and retailers and private equity investors are following suit. As noted above, owning physician practices enables conglomerates to inflate the perceived disease burden of patients, thereby enhancing capitation-based payments from the government. Vertical consolidation also enables patient steering: conglomerates can push patients to receive care at their own provider subsidiaries. In doing so, these companies squeeze out local providers, such as independent physician practices and community pharmacies. Steering also generates “captive revenue,” which allows conglomerates to game federal regulations requiring that government payments are spent on patients, not profits. Further, these conglomerates use their insurance-side subsidiaries to pressure independent practices to sell to their provider-side subsidiaries, effectively “flipping” new patients to their own medical practices and insurance plans.

Turning to solutions, Part III of this paper argues for an alternative policy framework— aimed at a new “industrial policy” for health care—that would depart from the Capitation Consensus and center at least three principles. First, this approach would be suspicious of concentrated corporate power—whether horizontally or vertically combined—and would promote the autonomy and collective power of clinicians. Second, it would revive a legal and policy focus on the ownership structure and governance of health care providers, protecting the medical profession from corporate influence and minimizing financial strategies that increase prices and administrative costs. Third, a proactive health care industrial policy would emphasize the “supply side”: how policymakers, particularly in Medicare, can exercise greater control of public money and directly rationalize the production and allocation of health care capacity.

The paper offers two sets of policy recommendations. The first would directly combat the emerging forms of vertical consolidation that are fueled by the Capitation Consensus. The second set of policies offers alternatives to large-scale, investor-driven health care. These proposals are geared toward building robust health care infrastructure—owned by clinical providers and local communities—that meets growing care needs and is insulated from corporate consolidation.

full policy brief:
http://www.economicliberties.us…

A Doctor at Cigna Said Her Bosses Pressured Her to Review Patients’ Cases Too Quickly. Cigna Threatened to Fire Her.

Cigna tracks every minute that its staff doctors spend deciding whether to pay for health care. Dr. Debby Day said her bosses cared more about being fast than being right: “Deny, deny, deny. That’s how you hit your numbers,” Day said.

By Patrick Rucker and David Armstrong
ProPublica, co-published with The Capitol Forum, April 29, 2024

In late 2020, Dr. Debby Day said her bosses at Cigna gave her a stark warning. Work faster, or the company might fire her.

That was a problem for Day because she felt her work was too important to be rushed. She was a medical director for the health insurer, a physician with sweeping power to approve or reject requests to pay for critical care like life-saving drugs or complex surgeries.

She had been working at Cigna for nearly 15 years, reviewing cases that nurses had flagged for denial or were unsure about. At Cigna and other insurers, nurses can greenlight payments, but denials have such serious repercussions for patients that many states require that doctors make the final call. In more recent years, though, Day said that the Cigna nurses’ work was getting sloppy. Patient files that nurses working in the Philippines sent to her, she said, increasingly had errors that could lead to wrongful denials if they were not corrected.

Day was, in her own words, persnickety. If a nurse recommended denying coverage for a cancer patient or a sick baby, she wanted to be certain it was the right thing to do. So Day said she researched guidelines, read medical studies and scrutinized patient medical records to come to the best decision. This took time. She was clearing fewer cases than many of her peers.

Some of her colleagues quickly denied requests to keep pace, she said. All a Cigna doctor had to do was cut and paste the denial language that the nurse had prepared and quickly move on to the next case, Day said. This was so common, she and another former medical director said, that people inside Cigna had a term for these kinds of speedy decisions: “click and close.”

“Deny, deny, deny. That’s how you hit your numbers,” said Day, who worked for Cigna until the late spring of 2022. “If you take a breath or think about any of these cases, you’re going to fall behind.”

In a written response to questions, Cigna said its medical directors are not allowed to “rubber stamp” a nurse’s recommendation for denial. In all cases, the company wrote, it expects its doctors to “perform thorough, objective, independent and accurate reviews in accordance with our coverage policies.” The company said it was unaware of the use of the term “click and close” and that “such behavior would not be tolerated.”

During Day’s final years at Cigna, the company meticulously tracked the output of its medical directors on a monthly dashboard. Cigna shared this spreadsheet with more than 70 of its doctors, allowing them to compare their tally of cases with those of their peers. Day and two other former medical directors said the dashboard sent a message loud and clear: Cigna valued speed. (ProPublica and The Capitol Forum found these other former Cigna doctors independently; Day did not refer them.) One of Day’s managers in a written performance evaluation called the spreadsheet the “productivity dashboard.”

Measuring the speed and output of employees is common in many industries, from fast food to package delivery, but the use of these kinds of metrics in health care is controversial because the stakes are so high. It’s one thing if a rushed server forgets the fries with your burger. It’s another entirely if the pressure to act fast leads to wrongful denials of payment for vital care. Walgreens in 2022 dropped measurements of its pharmacists’ speed from their performance reviews after some alleged that practice could lead to dangerous mistakes.

ProPublica and The Capitol Forum examined Cigna’s productivity dashboards for medical directors from January and February 2022. These spreadsheets tallied the number of cases each medical director handled. Cigna gave each task a “handle time,” which the company said was the average amount of time it took its medical directors to issue a decision.

Day and others said the number was something different: the maximum amount of time they should spend on a case. Insurers often require approval in advance for expensive procedures or medicines, a process known as prior authorization. The early 2022 dashboards listed a handle time of four minutes for a prior authorization. The bulk of drug requests were to be decided in two to five minutes. Hospital discharge decisions were supposed to take four and a half minutes.

“Medical directors would message me and say, ‘We can’t do these cases in four minutes. Not if you want to do a good job,’” Day recalled.

As ProPublica and The Capitol Forum reported last year, Cigna built a computer program that allowed its medical directors to deny certain claims in bulk. The insurer’s doctors spent an average of just 1.2 seconds on each of those cases. Cigna at the time said the review system was created to speed up approval of claims for certain routine screenings; the company later posted a rebuttal to the story. A congressional committee and the Department of Labor launched inquiries into this Cigna program. A spokesperson for Rep. Cathy McMorris Rodgers, the chair of the congressional committee, said Rodgers continues to monitor the situation after Cigna shared some details about its process. The Labor Department is still examining such practices.

One figure on Cigna’s January and February 2022 dashboards was like a productivity score; the news organizations found that this number reflects the pace at which a medical director clears cases.

Cigna said it was incorrect to call that figure on its dashboard a productivity score and said its “view on productivity is defined by a range of factors beyond elements included in a single spreadsheet.” In addition, the company told the news organizations, “The copy of the dashboard that you have is inaccurate and secondary calculations made using its contents may also be inaccurate.” The news organizations asked what was inaccurate, but the company wouldn’t elaborate.

Nevertheless, Cigna said that because the dashboard created “inadvertent confusion” the company was “reassessing its use.”

Day was afraid to look at the dashboards. Anyone could see that by Cigna’s measures, she was a laggard. In January 2022, only a third of her peers had lower scores, and in February 2022, it was just a quarter.

In a recorded phone call and in emails with supervisors, Day complained that Cigna’s metrics failed to account for the quality of decisions. She said she and others asked higher-ups how often medical director decisions were overturned on appeal but nobody would say.

Day gave Cigna written permission to discuss her employment with ProPublica and The Capitol Forum.

The company described Day as a “disgruntled former employee” and said her “personal view is not an accurate representation of the work of the many medical directors and clinicians we employ.” Cigna added that prior authorization requests are often time-sensitive and the company’s “mission is to ensure our patients receive the right care as quickly as possible.”

Cigna rejected the assertions that denying cases was an effective way of working faster. “Even if medical directors were incentivized to review more claims — which they are not — it makes no sense to suggest that this incentivizes denials; it would be far quicker to approve all claims,” the company spokesperson wrote. The insurer said that denials take more time because they require a deeper review of clinical data, potentially requesting additional reviews by senior clinical directors, drafting denial letters and possibly phoning the treating physicians.

But another doctor who had worked at Cigna also said that denying a request for payment was far quicker than approving one since the nurses served up language that could be used to justify the denial. That former Cigna medical director said, “Sometimes you just have to accept the nurse and click and close if you had too much work.” (That doctor asked not to be named because they feared repercussions if they commented publicly.)

When Debby Day got her job at Cigna in November 2005, she thought it was a godsend.

She had been working for a health insurance startup in North Carolina. The charismatic founder of the company, Day said, had told her and a handful of principal executives to expect a windfall when the company went public. That never happened, and Day was eventually left with no job and no severance.

When a recruiter mentioned the medical director job at Cigna, it sounded like a perfect fit. The job was based in North Carolina, but Cigna didn’t mind that she was licensed in California, where she did her residency at Harbor-UCLA Medical Center. She was ready to leave the executive track, and the position allowed her to put her medical training to good use without the daily grind of working in a clinic.

The daughter of an ophthalmologist, Day had watched her father perform eye surgery when she was a child, and she found medicine fascinating. When Day started practicing, she learned quickly that while she enjoyed the intellectual challenges of medicine, the hands-on work of seeing patients drained her. As a medical director, she said, “I could really take care of patients without having to talk to them all day long.”

Cigna, like all health insurers, makes patients get approval in advance for certain treatments. Day became one of the people who reviewed these prior authorization requests, deciding what to cover and what to deny. Everyone Day worked with was under one roof in Raleigh, North Carolina. The office buzzed with conversations among colleagues, and she was able to consult with specialists on complex cases.

She never felt pressure to do anything but make the right decision for the patient. At the same time, she said, she didn’t hesitate to reject treatment she thought was improper.

A couple years into her time at Cigna, Day noticed some doctors prescribing a costly treatment called intravenous immunoglobulin, or IVIG, that helps patients with weakened immune systems fight off infections. Only she found they were prescribing it in cases where it didn’t make any medical sense. That wasn’t good for patients or for Cigna. “Some of these guys were pouring it into every patient they could get their hands on and then making hundreds of thousands of dollars billing for it,” she recalled.

At the time, Cigna didn’t have a policy for when IVIG should be used, so Day developed one based on the scientific evidence available at the time. Day said this saved millions of dollars and that Cigna rewarded her with bonuses and stock options.

“In my head I truly believed that you could marry good health care with business,” she said.

As Day neared the end of her first decade at Cigna, the company closed regional offices in favor of a nationwide review system, she said. With medical directors working from home, Day could no longer pop down the hallway to consult with doctors in other specialities.

Cigna had used a productivity dashboard for years, but by 2019, these metrics began playing a more prominent role in the company’s evaluations of medical directors, Day said. Now, making a fast decision seemed more important than making the right decision, she said. In February 2019 emails to her managers, Day openly questioned this system.

Her boss responded: “We all understand that many cases are involved and take more time,” he wrote. “We have tried to account for that additional time in the allotment allowed for certain cases.”

Still, he made it clear that transaction volume — the metric on the dashboard that was similar to a productivity score — was one of the factors “we use to determine merit raises, bonus” and stock awards. When asked about this, Cigna said that “any assertion that our Medical Directors’ compensation (cash or stock) is tied to denials or their handle time for cases is false.”

In that same 2019 email, Day’s boss added, “We want to assist every medical director who wishes to improve his or her efficiency.”

Day shot back, “Some of our newer MDs are quite terrified of the ‘counting,’” she wrote. “All ask — ‘how is quality measured?’”

Soon, Day realized that her boss wasn’t talking in the abstract about improving efficiency; he was talking about her. She learned that managers were going to help her pick up the pace of her reviews.

When bosses reached out, they didn’t discuss whether she was making the right call, only how long it took her to decide, she said.

By then, Day said, Cigna had shifted much of the nursing work to the Philippines. She found mistakes in the case files that these nurses sent. In an email to Day, a fellow medical director lamented the amount of time it took to untangle one case and said the reports by “the overseas nurses” were “messes.”

Some of the more astonishing problems that Day spotted have stayed with her. In a case involving a newborn who needed an epilepsy evaluation, Day noticed that a Cigna nurse had listed the mother’s name as the patient, rather than the baby’s. Day fixed that mistake, avoiding what certainly would have been a denial. In another case, a nurse recommended denying payment for an ultrasound of the neck because the treatment wasn’t medically necessary. But the nurse had gotten the body part wrong. It was a hip that was injured, and the imaging was needed. An appeal that landed on Day’s desk involved Cigna’s decision to reject payment for a test because it wasn’t medically necessary for a patient with a sexually transmitted disease. But Day figured out that the patient had toenail fungus, not an STD.

Day said her bosses didn’t want to hear that she was catching errors. By October 2020, Cigna had placed Day on a performance improvement plan that required her to raise her “productivity level” — referring to the score on the dashboard — to at least 70%, which would be a significant jump for her but was slightly below the median for medical directors. The company made the consequences crystal clear: If she failed to successfully complete the plan, she could be terminated.

ProPublica and The Capitol Forum asked Cigna how it calculated that score, but the company wouldn’t say. “Transaction volume helps gauge productivity and efficiency — the amount of work done, not the speed at which it is done,” a Cigna spokesperson wrote. The company said this metric measured the time a medical director spent on tasks involving medical judgment versus other work, such as internal meetings or training.

On the early 2022 productivity dashboard, though, a different calculation could explain Day’s score, and this math reflects how fast medical directors reviewed cases. ProPublica and The Capitol Forum multiplied the number of cases Day handled by the time Cigna allotted for each type of case, then divided that total by the hours she worked that month. The resulting percentage equaled her score. Medical directors who spent every available minute of their workdays clearing cases within the time constraints Cigna set would score at least 100%. Indeed, some medical directors had scores greater than 100%, meaning they cleared cases in even less than the allotted time. The newsrooms’ formula accurately reproduced the scores of 87% of the Cigna doctors listed; the scores of all but one of the rest fell within 1 to 2 percentage points of the number generated by this formula. When asked about this formula, Cigna said it may be inaccurate but didn’t elaborate.

Day said her bosses told her that the way to boost her score was to review more cases during her normal work hours.

Responding to questions, Cigna said the productivity dashboard was “primarily used to ensure that we have enough medical directors to perform the amount and type of work that needs to be done.” It is not used, the company said, to evaluate the performance of medical directors or track the speed at which individual doctors do their work.

Cigna, however, later said of the dashboard that “in the unusual situation that a medical director is a significant outlier to peers performing similar types of reviews, managers might use this metric as one data point to understand and discuss the variance with the medical director.” It also said Day was placed on a performance improvement plan “to help her meet the most basic standards to support patient care.”

During the time Day spent on the performance improvement plan, she refused to change her approach, which she felt was necessary to make the right call.

In December 2020, she appealed to the human resources department, figuring that colleagues there would see that it was wrong to fire a medical director for taking care to decide critical medical questions.

She was wrong.

“You feel that the time constraints/metrics, which are in place to review these cases are unreasonable, for some cases are very complex consisting of multiple pages to review,” a Cigna human resources employee wrote, summing up Day’s feelings as the matter escalated.

And while Day’s supervisor “appreciates your attention to detail,” the human resources employee wrote, he “also realizes that there are metrics in place that he must hold everyone to.”

When asked about this, Cigna said, “Dr. Day raised questions about her performance improvement plan through appropriate internal ethics channels available to all employees, and there was no wrongdoing found.”

Eventually, the daily stress of being pushed to work faster coupled with the threat of being fired took a toll on Day. Sleepless and fighting depression, Day was at the breaking point.

“I actually sort of had a mental breakdown,” she recalled.

On a recorded call with her boss about her lagging productivity score, Day brought the subject back to the quality of the decisions she was making. Her boss made it sound like Day was a broken record.

“We have the same discussion every time we talk,” he said. While saying “nobody’s asking you not to do quality work,” her boss said, “you must know I just have to redirect our discussion.”

But Day continued: “When there is no measurement of quality, then the discussion will continue to have that element to it.”

The supervisor said he heard Day’s concerns “loud and clear” but warned that “at the end of the day, we need to get your productivity up and we don’t have a lot of time to do that.”

The focus on metrics was proof Cigna was losing its way, Day told her boss. When she started working at Cigna 15 years earlier, there was a “commitment to quality and taking care of our customers.” Day said that it was still important to her and other medical directors that “we go home at the end of the day and think we’ve done a good job for Cigna.”

In a response to questions, Cigna said the supervisor, who works in California, was unaware that he was being recorded and that under that state’s laws, it is illegal to record a private phone call without all parties’ consent. Day said that she was in North Carolina during the call and that North Carolina law allows a person on a call to record without getting the consent of others.

Day took a monthslong leave from the job in mid-2021 that allowed her to work part time, and she found a therapist who helped her manage the depression. When she returned, Day said, it was more of the same.

In the late spring of 2022 she decided to retire from Cigna.

Maya Miller contributed reporting.

https://www.propublica.org…

Medicare for All Individual Cost Calculator

Medicare for All saves money overall … but what will it mean financially for specific individuals and families? That’s the question this new calculator answers for national M4A, in just a few minutes.

Congresswoman Pramila Jayapal, Email to supporters, April 25, 2024

Republicans HATE Medicare for All and they’re doing everything in their power to protect Big Pharma and our private, for-profit health care system.

This 100% free and accessible calculator compares the information you give for current spending on health care and your Medicare for All spending based on a progressive tax model proposed to fund the program. All you need to do is click here to get started ››

Use the Medicare for All Calculator ››

You may be asking yourself, what would Medicare For All accomplish?

The answer is: SO MUCH! Medicare for All will pay for all medically necessary care. Just look at everything it would cover:

  • Inpatient, outpatient, emergency, and preventive care
  • Dental, vision, and hearing care
  • Prescription drugs
  • Lab and diagnostic services
  • Medical devices
  • Reproductive health care such as abortion, prenatal care, infertility treatment and more
  • Gender affirming care
  • Physical therapy and rehabilitation
  • Emergency and necessary transportation
  • Long term care supports and services
  • Hospice care
  • Mental health care
  • Telehealth
  • AND MORE!!!

Our calculator is an accessible tool for disassembling Republican disinformation and fear mongering about Medicare For All. Using this calculator is incredibly easy and FREE. So please, take a moment and use our new Medicare For All calculator! ››

Comment:

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

The many economic analyses which demonstrate that single payer would reduce US health care costs fall short in one crucial way: they don’t indicate how any particular person or family will fare financially. Understandably, people want to know – how will this kind of program affect my costs? Since there will be some new taxes, maybe I’m at risk of paying more.

That’s the question the on-line calculator is designed to answer. Full disclosure – I led the technical team that worked with Congresswoman Jayapal and her staff to implement this calculator.

The calculator uses estimates from the Congressional Budget Office of how much new revenue the federal government would need to fully fund Medicare for All as specified in Rep. Jayapal’s bill. We designed a tax strategy to generate that revenue. It includes a 1.65% payroll tax; a progressive income tax starting at 1% at $178,000 for joint filers and $89,000 for single filers, and rising to 11%; a 15% tax on corporate profits; and a 3% wealth tax on individuals with >$30 million in assets.

The calculator asks for the user’s prior year costs – premiums and out-of-pocket spending. And asks for income; this determines the new taxes. And then, simple math, the calculator compares the two, yielding net savings (or costs).

We did a California calculator in 2022. This national calculator is very similar, with a refined tax strategy and two additional questions. As we reported in HJM for California, “Four thousand individuals reporting current healthcare spending and income reveal that … nearly 9 in 10 will save money, more than $5000 per year on average, with single payer.”

We’re eager to see the results on the national level. So — visit and use the site!

Geek comment: we’ll be able to explore the impact of different tax strategies on the distribution of savings and costs.

We hope the calculator will be a valuable organizing tool – to inform, energize, and advocate for Medicare for All. Please share information about the calculator widely via email, social media, and other channels.

https://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.

The Tragicomedy of Medicaid

Millions have been disenrolled from Medicaid, nominally due to the “unwinding” of COVID eligibility rules … but also due to administrative glitches. Lots of other problems with Medicaid. It’s a crisis, worthy of the deep scrutiny and biting wit of John Oliver.

Medicaid: Last Week Tonight with John Oliver (HBO), (28 minute video), April 18, 2024

John Oliver discusses why millions of people have been kicked off of Medicaid, why Medicaid access was difficult even before the current “unwinding”, and what would happen if fruits and vegetables could talk.

[Alert: Oliver uses profanity for emphasis]

Comment:

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

It’s so tragic it’s comic. Medicaid – health insurance for 90 million US poor – is a vivid example of the chaos and inefficiency that result when a program is designated and designed for individuals who lack political power and social standing. The beneficiaries are disrespected and poorly served. As HJM discussed, in most states private “managed care” insurers exploit the massive Medicaid cash cow to extract profits via restricted services and higher government spending. This essential health insurance lifeline is frayed.

What we need is a public insurance system that serves everyone, and thus is subject to natural quality control. Everybody needs it, so it works. Think social security, fire departments, and highways. They function well, fulfilling important societal functions.

In the health insurance arena, that’s single payer / Medicare for All. Successfully implemented around the world. Generous, equitable, and efficient. Advocated by John Oliver.

Oliver’s plea in this video for better management of Medicaid unwinding is appropriate, but IMO doomed to succumb to the dysfunctional dynamics of the Medicaid system. Hence my – and Oliver’s – plea for real system reform.

Universal public insurance is a heavy political lift, due to all the private entities – most of all insurers – who will lose tens of billions in profits. So we need to keep up the fight. John Oliver is our best cheerleader.

https://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.

Political Party Split vs. Concurrence on Government Guarantee of Health Care

The Dem and GOP party split is nearly equal. Yet, we largely concur on worries about health care availability and affordability, and on a government role to assure we all have health care. Medicare for All / single payer is the path.

Changing Partisan Coalitions in a Politically Divided Nation, Pew Research Center, April 9, 2024

The combined effects of change and continuity have left the country’s two major parties at virtual parity: About half of registered voters (49%) identify as Democrats or lean toward the Democratic Party, while 48% identify as Republicans or lean Republican.

The continuing close division in partisan identification among voters is consistent with the relatively narrow margins in the popular votes in most national elections over the past three decades.

American Anxieties, GALLUP, April 9, 2024

Tell me if you personally worry about this problem a great deal, a fair amount, only a little or not at all.

The availability and affordability of healthcare [fifth item on the list]

  • 51% – A great deal
  • 27% – A fair amount
  • 21% – Only a little/Not at all

Comment:

By Don McCanne, M.D.

Over three-fourths of our nation (78%) is concerned about the lack of availability and affordability of health care. And yet the political activity we see is some nominal support of private insurance patches on the part of Democrats, when private insurance is proving often to be a detrimental method of funding health care, and Republican proposals to pass more of the costs on to patients through high deductibles and schemes such as health savings accounts. These political “solutions” actually result in the perpetuation of problems with both the availability and affordability of health care.

With three-fourths of the nation quite concerned, that certainly includes both Republicans and Democrats. Surely most of them do not believe that health care reform calls for a mandate of a private sector solution because that is what is available to everyone right now through the private insurance market. Without insurance, most cannot afford to pay for a major medical event or at least do not want it to displace other expenditures such as a down payment on the home they wanted to buy, the kids’ college education expenses, or funding of their retirement programs. But today, the private insurance industry and other intermediaries have become additional major sources of increased expenses and barriers to health care since those entities are on a mission to prioritize increasing investor wealth over patient health.

The majority of Americans want the federal government to guarantee health care and don’t trust insurers. Almost everyone approves of the government making health care available and affordable for people over 65, in the form of Medicare. In recent years, efforts have been made to privatize Medicare and that needs to be reversed by eliminating private insurers in order to return to patient care as guiding priority. Also, the benefits need to be expanded (vision, hearing, long term care, etc.) and deductibles and copayments should be eliminated so that Medigap insurance would no longer be necessary. Then, with other improvements, this version of Medicare should be expanded to include absolutely everyone, and it would be made equitable by funding it with progressive taxes, recovering some of the excessive revenues that have been moving into the coffers of the billionaires and the mega trillion dollar corporations.

Surely the large majority of us who are concerned about the availability and affordability of care can see the fairness in the rewards of our productivity that have been siphoned off by the super-rich being returned to us in funding for health care for all. No more silly knee jerk reactions against the labels “single payer” or “Medicare for All.” They will be labels that we can all be proud of because we earned them.

https://healthjusticemonitor.org…

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

Medicare for All Explained Podcast: Episode 110

We don’t Need Health Insurance Companies

April 15, 2024

Podcast host Joe Sparks relates a recent experience filling a prescription at Costco to remind us that corporate health insurers add nothing of value to U.S. health care.

When he asked his pharmacist how much his prescription would cost if he paid out of pocket, he was surprised to learn that, “I paid four times less when I did not use my insurance.”

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

https://medicareforallexplained.podbean.com

Big corporations are quietly taking over your medical practice. Some doctors and experts say it’s ruining healthcare.

By Shelby Livingston
Business Insider, April 11, 2024

  • Big businesses such as hospital systems, insurers, and PE firms are gobbling up medical clinics.
  • Some doctors and industry experts fear corporate owners could prioritize profits ahead of patients.
  • The federal government is dialing up scrutiny of PE firms and other corporate owners in healthcare.

Independent doctors are almost a thing of the past.

UnitedHealth Group struck a deal in March to buy the nine-state doctor group of the struggling hospital system Steward Health Care. The same month, the powerful healthcare conglomerate, which owns the nation’s largest health insurer, got the green light to take over a decades-old independent Oregon medical practice, adding another 100 healthcare providers to its roster. It picked up a 400-doctor group in New York about a year before.

These are just the purchases we know about; there could be many more. Physician practice deals often go unannounced and get little attention from regulators, but they add up. Near the end of 2023, UnitedHealth’s Optum, the business unit housing its clinics and surgery centers, said it employed or was affiliated with 90,000 doctors. That’s a whopping 10% of all doctors in the US.

Though it’s the hungriest, UnitedHealth is just one buyer in the market for physicians. Little by little, big businesses have taken over healthcare in the US.

Hospitals have been scooping up medical practices for decades to create giant health systems. Insurance companies fought back with their own clinic purchases. Private equity firms increasingly staked claims to nursing homes and groups of specialists such as emergency physicians and dermatologists.

And in the last few years, tech companies and retailers like Amazon, CVS Health, and Walgreens added thousands of doctors to their payrolls when they bought primary-care chains.

Nearly 78% of US doctors are employed by hospitals or other corporate entities, such as insurers and PE firms, according to research from consultancy Avalere and the Physicians Advocacy Institute. For the first time, more medical practices were owned by corporate entities (30%) than hospitals (28%) as of January 2024, the research found.

There’s mounting evidence that this trend toward corporatization could harm patients. Research has found that prices go up when hospitals and private-equity firms buy medical groups. Sometimes, care gets worse, but there’s still much unknown about how corporate ownership affects medical care, especially when it’s a giant like UnitedHealth or CVS doing the buying.

Some doctors and experts in the industry fear corporate owners could prioritize their investors and profits ahead of patients, and doctors could lose the ability to make their own decisions about what’s best for a patient.

“The big guys aren’t cheaper. They don’t deliver better customer service, they aren’t more timely, none of that. They’re just able to negotiate higher prices,” said Farzad Mostashari, the CEO of Aledade, a company that aims to help primary care practices stay independent.

The federal government is starting to pay attention. In March, it launched an inquiry into PE firms and other corporate owners’ “increasing control over healthcare” and how this might threaten patients’ access to affordable and quality care.

The feds also zeroed in on UnitedHealth, reportedly facing an antitrust investigation by the US Justice Department into how its medical group acquisitions affect consumers and competitors. News of the probe surfaced before a cyberattack on UnitedHealth’s technology business, Change Healthcare, caused hospitals and clinics nationwide to forgo billions in payments — raising more questions about UnitedHealth’s chokehold on the healthcare industry.

Doctors are hot commodities

It’s tough to lump the many buyers of medical practices together, as they’re pursuing different strategies. But, in essence, they’re all hiring doctors for their relationships with patients, who bring opportunities for more profits. US healthcare spending reached $4.5 trillion in 2022, representing almost a fifth of the national GDP.

Hospitals rely on doctors — especially those who provide primary care — to refer patients for lucrative procedures or surgeries. Insurers like UnitedHealthcare and CVS’ Aetna are required by federal law to spend most of the money they collect in premiums on medical care. Still, they can pocket more of those premiums by sending patients to clinics they own.

Pharmacies hope that buying medical practices will give more prescriptions to fill and get more customers to buy over-the-counter products at the front of the store.

“They all realize that patients will follow what their doctors tell them to do or where their doctors tell them to go,” said Chas Roades, a longtime healthcare consultant. “So it allows them to both drive traffic to a downstream profit model that they’re interested in growing, and I think it also is a way to get consumers to trust them.”

Meanwhile, independent doctors have a tough time going it alone. Reimbursement is shrinking, and small practices don’t have the ability to negotiate higher rates as big hospital systems do. Plus, running a modern medical practice is expensive, requiring investments in staffing, technology, and electronic health records. The pandemic made things even more challenging, spurring many doctors to sell their private practices.

The quiet takeover of physician practices

Much of the takeover of physician practices has slid under the radar. That’s because acquisitions valued below $119.5 million don’t have to be reported to federal regulators, and many practice purchases don’t meet that threshold. Publicly traded UnitedHealth, for instance, rarely announces its purchases of medical groups and surgery centers.

“We’re really flying blind here with respect to understanding how many acquisitions by which entities and what geographies and what specialties,” said Yashaswini Singh, an assistant professor at Brown University who studies healthcare consolidation.

This lack of disclosure has made consolidating doctor practices difficult to study. Research into private equity’s effects on healthcare is just emerging, and there’s little to no academic, peer-reviewed research on how other corporate owners’ acquisitions affect healthcare prices and quality, Singh said.

Studies, including Singh’s research, have shown, however, that PE ownership leads to steeper prices and more utilization, meaning patients may have more frequent doctor’s appointments. Together, that drives healthcare costs higher. Research also suggests that PE ownership of nursing homes and hospitals worsens the quality of care. One paper found that patients who went to nursing homes owned by private equity firms had a 10% greater chance of dying.

And yet, private equity companies are rapidly expanding their presence in healthcare. A 2023 study found that one private equity firm owned 30% of the market share for physician practices in over a quarter of metropolitan areas across the US. A single PE firm owned over half the market share in some areas.

‘An unsatisfying way of practicing medicine’

Acquisitions by other corporate giants might not produce the same outcomes as PE firms, said Zirui Song, an associate professor of healthcare policy and medicine at Harvard Medical School who studies private equity in healthcare. PE firms are unique in holding on to their acquisitions for only a few years and saddling their acquired companies with debt and fees. Owners who hang on to their medical groups might be more motivated to improve services, he said.

Anecdotally, though, many doctors don’t like working for corporate overlords, Roades said. Older physicians who own equity in their medical practice get a nice payday when they sell, but the younger ones left behind are closely managed and measured in terms of cost and productivity, he added.

It’s “an unsatisfying way of practicing medicine. We’re seeing a growing number of disgruntled early and mid-career physicians in these groups who find themselves suddenly working for large corporations, and this is not what they wanted to do with their lives,” he said.

After a few years working at Optum-owned Oregon Medical Group, Dr. Nick Jones opened a direct primary care practice, a type of clinic that charges a monthly fee instead of billing insurance. He said there’s a sense of powerlessness for primary-care doctors in the traditional healthcare system — whether they’re employed by Optum, a large hospital system, a private-equity firm, or a nonprofit clinic.

With thousands of patients to treat, they face a mountain of administrative paperwork and have no control over their schedules. These problems stem from the fact that primary-care doctors are underpaid in the traditional “fee-for-service” healthcare system, in which doctors are paid for every visit, he said.

While he felt supported at his previous Optum-owned clinic because of his office manager, “the financial underpinnings and the economics of medicine” made it unsustainable and stressful, Jones said. “There was a three or four month wait for patients to see me. There was still too much on our plate to do, and [during the pandemic] there weren’t enough medical assistants or case managers or nutritionists or other support to make 20 patients a day feel like the right thing to do.”

Doctors worry corporate giants put profits over patients

The insurers and retailers say care is better and cheaper when integrated under one roof, connected to the health plan, pharmacy, or other provider organizations.

For its part, Optum says it wants to improve the health and well-being of people and lower the cost of care with integrated care teams and better technology. It says it’s helping clinics transition to providing “value-based” or “accountable” care, which means that its doctors get paid fixed fees upfront that, in theory, encourages them to keep patients healthy and order fewer unnecessary tests.

Optum said in a statement it continues “to focus on supporting physicians, advance practice clinicians, and nurses in closing gaps in care and helping the health system perform better for everyone.”

A spokesperson pointed to a study by Optum published in JAMA Network Open in December 2022 that found seniors in value-based care arrangements were less likely than seniors in traditional payment models to visit the emergency room, or be admitted at the hospital for COPD, asthma, stroke, or heart attack.

But there are potential dangers. Patients may end up with fewer choices as bigger companies edge out competitors.

California health system Emanate Health sued Optum in 2023 for anticompetitive behavior. It alleged that Optum canceled its contracts with Emanate hospitals and steered patients away after Emanate refused to agree to certain terms. Among the terms: Emanate primary-care doctors would serve only Optum patients, and Optum would get first dibs if Emanate decided to sell its primary-care practices.

Care might also feel less personal. Some One Medical patients complained that since the chain folded into Amazon, their appointments were shortened, and certain features for seniors, like having health coaches available during patient visits, went away, according to a report from The Washington Post.

Patients could end up spending less time with doctors and face higher costs

Dr. Mitch Li, an emergency physician who started Take Medicine Back, a group that opposes corporate owners pushing into healthcare, said patients will spend less time with their doctors and potentially face higher costs from predatory billing practices.

“The corporate practice of medicine is the reason why healthcare costs are out of control,” Li said.

Above all, some doctors fear having to make decisions that benefit the owner’s bottom line, even though they may not be the best option for a patient.

Dr. Michelle Cooke, a primary-care physician, previously practiced at an Atlanta clinic owned by a hospital system. Though the system was not-for-profit, it didn’t operate like that, and over time, the job became unbearable, she said.

She had more than 3,000 patients assigned to her care — far more than typical — and appointments were too short, especially for the chronically ill, she said. The hospital system would prioritize lucrative physicals for Medicare patients rather than seeing patients with an urgent need.

“It really got to the point where I feel like I was working to feed the corporation,” Cooke said. “It really wasn’t incentivizing what the patients needed.”

Cooke has since opened a direct primary care practice, where she sees just a few hundred patients and can spend more time with them. She said she’s found that she prescribes less medication now because she has time to educate patients on lifestyle habits and nutrition.

The federal government and states are dialing up the scrutiny

The Federal Trade Commission, the US Department of Justice, and the Department of Health and Human Services are stepping up scrutiny of healthcare deals, particularly those backed by private-equity firms. The agencies also signaled that they want to look at smaller deals that typically wouldn’t trigger an antitrust review.

Several states have also increased their oversight of local healthcare consolidation. Some state lawmakers are also trying to strengthen laws prohibiting corporations from practicing medicine. Most states have these bans on the books, but companies have found various ways around them.

It’s unclear if any of these efforts will meaningfully slow the corporatization of healthcare. And, to be sure, some physician practices may not have survived without an infusion of capital from a corporate buyer.

A bill introduced by Oregon State Rep. Ben Bowman would have closed certain loopholes and put more distance between corporate entities and their medical practices. Bowman told Business Insider he wanted to prevent big businesses from eroding doctors’ autonomy.

“A physician who went to medical school who took an oath — their highest ethical duty is to care for their patients. Whether it’s a private equity firm or a large corporation, their highest ethical duty is to generate a return on investment for their shareholders. Those two incentives are fundamentally at odds,” Bowman said.

The bill, opposed by Amazon and CVS, died in March, but Bowman said he plans to reintroduce it in 2025.

Around the same time the bill died, UnitedHealth’s Optum and The Corvallis Clinic — the small Oregon medical practice that Optum struck a deal to buy — requested that their tie-up receive an emergency exemption from state review because of the Oregon clinic’s deteriorating finances.

The proposed acquisition, first announced in December, had received plenty of pushback from state residents. The request also came as hospitals and clinics nationwide faced cash shortfalls because of the cyberattack on UnitedHealth’s Change Healthcare.

A week later, Oregon’s health authority approved the request.

https://www.businessinsider.com…

Cross-National Insurance Contrasts in Amusing 1-minute Videos

Two entertaining YouTube shorts highlight how the US lags on health insurance. Unaffordable premiums if you lose your job, and outrageous cost-sharing to give birth.

POV Losing Your Job in the US vs France, YouTube Short, Roya @royaventurera, March 29, 2024

[American accent] “Does this mean I lose my health care too? … You’re lucky you’re insured, you can actually continue your coverage through a program called Cobra, on average it’s about $700 every month … That’s almost my entire unemployment benefit! …

[French accent] what happens to my health care? Don’t worry your health care is not tied to employment in France …

Cost of Giving Birth Around the World vs US, YouTube Short, Roya @royaventurera, March 30, 2024

France? gratuit [free], Spain … Mexico … Brazil … all free

US? about 2-3 thousand dollars … if you do have insurance, otherwise could be 10-30-100 thousand … highest maternal mortality of any developed nation …

Comment:

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

These little dialogues bring a smile to my face (if not raucous laughter). I appreciate that, despite our dire insurance situation and my determination to reform the system.

The videos also remind us that all we need to do is adopt proven approaches to health insurance from other low (and middle!) income countries.

  1. Look around, outside our borders.
  2. Imitate.

Such an easy recipe.

https://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.

Protecting public health care from private investors

Private equity ownership of the places where we seek care risks undermining cost, quality, access, efficiency, and equity.

By Danyaal Raza, M.D., M.P.H. and Karen S. Palmer
Toronto Star, April 9, 2024

Private equity investment firms exist to make money for their investors. It’s their job. Over the past decade, private equity firms around the world have increasingly invested in the health care industry, including Canada’s long-term care sector and a growing number of private for-profit surgical centres.

Private equity firms are investment management companies. They buy other private companies with the intent to improve their performance, often selling them again a few years later at considerable profit to their shareholders.

In Canada, a single private equity firm already owns the largest national network of independent surgical centres — 53 operating rooms spread across 14 centres — in Quebec, Ontario, Manitoba, Saskatchewan, Alberta, and B.C.

Surgeries performed in these surgical centres are funded through a mix of public and private payments. Approximately 90 per cent are publicly funded through partnerships with provincial health systems. The remaining 10 per cent are private pay, including through private insurance or out-of-pocket for those who can afford it.

Some of that money is used to pay for patient care, but some — our public dollars — is extracted to enrich shareholders who expect a return on their investment.

Should profit-driven investors own health care facilities? Does it even matter, so long as patients get care?

Yes, it does.

Studies show that private equity ownership is associated with worse quality of care — such as a substantial increase in infections, falls, and other adverse events — and higher costs of health services around the world, including in the U.S., U.K., Sweden, Netherlands, and Germany.

Private equity ownership turns health care from a social good into a financial asset, extracting wealth for investors. There is no evidence that private equity ownership leads to systematic improvements in care. The primary focus is on financial gain for shareholders.

It’s not just surgical centres that are owned by these firms. Private equity has also scooped up nursing homes in Ontario, raising alarms about cost and quality of care. Tragically, these care homes had the highest mortality rates during the emergency phase of the COVID-19 pandemic and those with the highest profit margins suffered the lowest quality of care.

Although private equity ownership of Canada’s health care system is relatively new, it has become a mainstream and troubling phenomenon in the U.S. So much so that 25 per cent of U.S. hospital emergency departments are now staffed by private equity-owned staffing firms. Many worry that the growing financialization of health care inserts corporate values into treatment, raising concerns about the corporate practice of medicine.

Even the U.S. Federal Trade Commission has taken notice. For the first time ever, it is suing both a medical group and its private equity backers, alleging anti-competitive practices that drive up the cost of health care. Their concern is that this can exert pressure on health care professionals to “subordinate their own medical judgment to corporate decision-makers’ profit motives at the expense of patient health.”

Private equity firms are opaque and secretive. They don’t have to publicly disclose information about their finances, operations, business risks, or legal liabilities. Canadians are asking: What mechanisms are in place—like anti-trust and anti-competition legislation, regulation, and enforcement mechanisms — to guard against consolidation and the harms from monopoly corporate ownership and control of our health care delivery system?

Private equity ownership of the places where we seek care risks undermining cost, quality, access, efficiency, and equity. If we aspire to building a health care system that meets the demands of 21st century medicine, we must put in safeguards to ensure that corporate ownership, including by private equity firms, does not undermine all that we value in our health care system.

Dr. Danyaal Raza is a family physician at St. Michael’s Hospital, Unity Health Toronto and past chair of Canadian Doctors for Medicare. Karen S. Palmer is an adjunct professor at Simon Fraser University and University of Toronto and policy advisor to Canadian Doctors for Medicare.

https://www.thestar.com…

Latest Corporate Intermediary Scam, For Out-of-Network Charges

Here’s the latest corporate innovation to extract resources from health care, by creating yet another inefficient but highly profitable intermediary. This time it’s for out-of-network charges. Who pays more? Patients.

Insurers Reap Hidden Fees by Slashing Payments. You May Get the Bill, The New York Times, April 7, 2024, by Chris Hammy

MultiPlan is a little-known data analytics firm that works with UnitedHealthcare, Cigna, Aetna and other big insurers to decide how much so-called out-of-network medical providers should be paid. It promises to help contain medical costs using fair and independent analysis.

But a New York Times investigation, based on interviews and confidential documents, shows that MultiPlan and the insurance companies have a large and mostly hidden financial incentive to cut those reimbursements as much as possible, even if it means saddling patients with large bills. The formula for MultiPlan and the insurance companies is simple: The smaller the reimbursement, the larger their fee.

Here’s how it works: The most common way Americans get health coverage is through employers that “self-fund,” meaning they pay for their workers’ medical care with their own money. The employers contract with insurance companies to administer the plans and process claims. Most medical visits are with providers in a plan’s network, with rates set in advance.

But when when employees see a provider outside the network, many insurance companies consult with MultiPlan, which typically recommends that the employers pay less than the provider billed. The difference between the bill and the sum actually paid amounts to a saving for the employer. But, the Times found, it means big money for MultiPlan and the insurer, since both companies often charge the employer a percentage of the savings as a processing fee.

In recent years, the nation’s largest insurer by revenue, UnitedHealthcare, has reaped an annual windfall of about $1 billion in fees from out-of-network savings programs, according to testimony by two of its executives. Last year alone, MultiPlan told investors it identified nearly $23 billion in bills from various insurers that it recommended not be paid.

The little-understood financial incentive for insurers and MultiPlan has left patients across the country with unexpectedly large bills, as they are sometimes asked to pick up what their plans didn’t pay. In addition, providers have seen their pay slashed, and employers have been hit with high fees. In some instances, the fees paid to an insurance company and MultiPlan for processing a claim far exceeded the amount paid to providers who treated the patient.

After MultiPlan’s founder sold it to private equity investors in 2006, the company pursued a more aggressive approach. It embraced pricing tools that used algorithms to recommend lower payments, and no longer protected patients from having to pay the difference.

Once insurers were no longer obligated to use the nonprofit database, FAIR Health, they began looking for ways to combat billing and other charges they considered egregious. Insurers contended that overbilling would skew payments too high. Cigna: “We need someone external to Cigna to develop acceptable rates.” UnitedHealthcare emphasized companies still using FAIR Health, “understand they don’t want to be on that program anymore.”

UnitedHealthcare had a big incentive to encourage this change. When it processed claims from employer plans using FAIR Health, the insurer collected no additional fee. But when it used MultiPlan, it typically charged employers 30 to 35 percent of the difference between the billed amount and the portion paid.

MultiPlan, too, charged a percentage of the savings, meaning it could make more by recommending lower payments. (FAIR Health charged a flat fee.)

While UnitedHealthcare was MultiPlan’s largest customer, Cigna and Aetna also embraced its tools and fee model. Other insurers that work with MultiPlan include Kaiser Permanente, Humana and some Blue Cross Blue Shield plans. Employers with self-funded plans administered by insurers include large companies like Coca-Cola and AstraZeneca and smaller organizations like school districts and union locals.

Comment:

By Don McCanne, M.D. and Jim Kahn, M.D., M.P.H.

Theoretically, health insurance should allow us to equitably pool our funds in order to make health care both accessible and affordable for everyone participating. We have had a goal to expand that to include everyone. However, we have relied heavily on the private insurance industry which has engaged in business activities designed to increase profits for its shareholders and compensation for its executives. These activities have impaired access and resulted in an increase in medical debt for those for whom the system should be designed: the patients.

Not only are the insurers placing financial pressures on the physicians, hospitals, nursing homes and the many other providers of health care services, but they have also been attempting to further increase their incomes through increases in insurance premiums, deductibles, copayments, excessive prior authorization requirements, narrow provider networks, and limitations in coverage. Frequently these are applied in a manner that denies patients needed care, care that they can usually obtain if they are enrolled in a government program such as Medicare, Medicaid, VA Health if their particular program has not been overly privatized.

So what is the insurance industry offering us now? An example in the article: The physician provides medical services and bills $1000 for them. The self-insured employer pays the fee determined by MultiPlan which is only $200 of the $1000. The amount “saved” for the employer is $800 of which MultiPlan receives 7% or $56 and the insurer receives 35% or $280. A $800 balance remains which “the patient is potentially on the hook for.” Whether the patient or the physician is out the remaining $800 of the medical bill, clearly the insurers are no longer fulfilling what we consider the traditional function of insurers, yet they are leaching much of our health care dollars for worthless functions.

This is yet another intermediary strategy to extract profits. This time it focuses on out-of-network charges (those unregulated by the “No Surprises” Act). The “business model” is to add complexity via inserting extra corporate actors in a previously simpler arrangement. Just like Pharmacy Benefit Managers insert themselves between drug companies and pharmacies. They promise savings, but actually increase costs. This removes resources that should be spent on health care, and redirects them to shareholders of for-profit entities. Patients pick up the slack.

We’ve long said that it is time to get rid of the private insurers and their add-on leaches, and this development seems to make it even more of an imperative. It is high time to improve Medicare and to expand it to cover everyone as a single payer system that is equitably funded through progressive taxes.

Of the multitude of New York Times reader comments for this article the most popular was by a Canadian physician commenting on their single payer system who wrote,” The US needs to get their act together.

https://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.

Do No Harm

Exploring Chicago’s rich history of physician activism

By Judith Weinstein
Chicago Health, April 8, 2024

The day that physician residents and fellows at Northwestern Medicine voted 794 to 148 to unionize, some shared their joy on social media.

“So proud of the community of residents and fellows who made this happen. Unions increase workers’ democratic voice; raise wages and build wealth; and improve conditions for all workers. WE DID IT,” wrote third-year resident Hebron Kelecha, MD, on X (formerly Twitter).

Northwestern Medicine’s physicians-in-training aren’t Illinois’ first group to unionize (800 residents at University of Illinois Chicago unionized in 2011), but Northwestern’s group is the largest in the Midwest, with almost 1,300 doctors.

While the idea of physicians unionizing is relatively new, activism among physicians isn’t. Physicians regularly advocate for their patients. Many operate under the Hippocratic concept of, “First, do no harm.” 

But what if the harm is coming from beyond anything the physician and patient can control, such as from the environment, structural racism, insurance companies’ denial of care, or lack of access to healthy food?

The antibiotic prescribed for a single mother’s urinary tract infection, for example, may be less important to her than finding a job that pays a living wage, securing childcare for her two children, and moving to a safer neighborhood. The hernia repair operation that a laid-off factory worker needs may be less important to him than his lack of health insurance, his need to acquire skills in order to find a new job, and his concern about making rent payments while unemployed.

That’s when a physician might switch from advocacy — working on behalf of an individual patient — to activism, which involves pushing for social and political changes that impact entire communities. Still, if physicians take an oath to do no harm, is fighting the systems that harm their patients considered activism? Or are they simply doing their job?

Twenty years ago, an issue of the American Medical Association’s Journal of Ethics focused on physician activism. In his opening letter, Editor Jeffrey Kullgren wrote, “If we are truly dedicated to improving the lives and well-being of our patients, and if we honestly care enough about the vulnerable persons that have trusted us to care for them, we have an obligation not only to provide health care of the highest quality, but also in some way, shape, or form to be active in public policy changes needed to better their lives.”

Former U.S. Surgeon General Antonia C. Novello, MD, DrPH, embodies that concept. “I loved the practice of medicine, where the focus is on individual patients, but early in my career I realized that my strongest interest is in improving the health of large population groups,” Novello said in an interview in the same Journal of Ethics issue. “I wanted to be able to do something about the major health issues facing people in this country, such as the need to increase access to healthcare for the uninsured, the need to ensure that the healthcare in this country is high-quality care, and the need to improve the health status of Americans through greater emphasis on prevention and healthy lifestyles.”

To address the issues, Novello went from the medical clinic to the political arena. Yet, for many physicians, activism — especially in the wake of Covid-19 — increasingly happens in the clinic and on the streets.

The legacy of Quentin D. Young, MD

Chicago is an epicenter of corporate and political power. It’s a city of health insurance and pharmaceutical companies, and the headquarters for many medical associations, including the American Medical Association. One of the country’s largest safety-net hospitals also calls Chicago home. John H. Stroger, Jr. Hospital (formerly known as Cook County Hospital or more commonly “County”) has attracted and shaped many physician activists, including the legendary Quentin D. Young, MD.

Young was born in 1923 on Chicago’s South Side, the son of immigrants from Eastern Europe. He attributed his activism to an early awakening to injustices far and near, including the impacts of segregation on Black people’s health. In 1981, he co-founded the Health and Medicine Policy Research Group (HMPRG) — an organization that would “uncover and challenge health inequities in Illinois.” The choice to list health before medicine in the name was deliberate.

Young believed fervently in healthcare for all — “Everyone in, nobody out!” was his mantra — achievable only through a universal-financing mechanism. Countries typically achieve universal health coverage through single-payer financing. Medicare, for example, is a form of single-payer healthcare; however, it’s not universal health coverage because not all U.S. citizens qualify for Medicare — only those age 65 and over.

The United States is the only high-income country in the world without universal health coverage. While most Americans agree that healthcare is a basic human right, how to finance such care, especially via the government, is as divisive a topic as abortion or politics. 

“For Quentin, it was a moral argument,” says Margie Schaps, HMPRG’s executive director since 1993. “He wasn’t a believer in incrementalism. If you want transformative change, small steps will not get you there. And Quentin wanted transformative change.”

The revolution did not happen in Young’s lifetime, but other generations of physicians influenced by his moral argument picked up the mantle. 

A direct descendant in the physician activist family is David Ansell, MD.  

Today’s physician activist leadership

To talk with Ansell is to receive a crash course in the social determinants of health and the industrial healthcare complex. He’s currently senior vice president for Community Health Equity at Rush University Medical Center and associate provost for Community Affairs.

Ansell went to medical school in upstate New York to “do good for people.” But when handed a stethoscope branded by Eli Lilly, he thought about leaving for forestry school. 

Unfortunately for the trees, Ansell stayed the course and upon graduation headed to Chicago with one intention: to train under Young, then-chair of medicine at Cook County Hospital.

“I came to Chicago because I was an activist, and I learned how better to be an activist,” Ansell says. 

Ansell’s 2011 book, County: Life, Death and Politics at Chicago’s Public Hospital, includes an introduction from Young and chronicles the history of Cook County and his years there.

Activism is part of the social medicine skills that Ansell and co-author Kristen Pallok, MD, describe as key in the 2022 AMA Journal of Ethics article “Should Clinicians Be Activists?” The article also explores reasons physicians may shy away from activism.

Some physicians may consider themselves apolitical, or they view any treatment as better than no treatment. Others might disagree that healthcare is a human right, or fear for their employment. And some physicians don’t think they have the time or expertise for health activism.

Ansell has never been one of those physicians. Rush University leadership tapped him after he’d spent 30 years working at Chicago’s safety net hospitals (more than half at County, the rest at Mount Sinai Hospital) to serve as its inaugural chief medical officer.

I thought, what the heck? It’s across the street,” Ansell recalls. 

The view from Rush changed his perspective entirely. 

“I understood for the first time how structural racism in health inequities were built into one street,” Ansell says. “There were two worlds, all tied to a capitalist system where White people have better insurance, and Black and Brown people are at the bottom.” 

He saw the contrast between those worlds most starkly in organ transplant patients. “In my 30 years at [Cook] County and Sinai, none of my patients ever got a life-saving organ transplant. But the organs transplanted into White patients all came from Black and Brown bodies.” 

Achieving equity

While demonstrating via sit-ins and marches can be an effective form of activism, using research to take on a system and force it to change is especially powerful. Under Ansell’s direction, Rush became one of the first hospitals in the country to establish health equity as a system strategy and measurable organizational priority.

Ansell believes that an increasing number of medical students come to Rush because of this strategy. The health equity and social justice leadership course is often oversubscribed, but medical students train across all curricula in anti-racism and health equity. 

And for Ansell, universal healthcare offers a direct path to more equitable healthcare. 

“The nature of our health system perpetuates this inequity that puts Black and Brown people at the bottom of the pile; it’s a caste system. Single-payer, or something like it, where everyone gets the same card at birth, will improve outcomes for the population,” he says, adding, “But that’s not enough.”

Physicians for a National Health Program (PNHP) advocates for universal, comprehensive single-payer national health insurance, joining with other organizations to fight racism and advance social justice. Founded in 1987 in Cambridge, Massachusetts, by Steffie Woolhandler, MD, and David Himmelstein, MD, the program moved its headquarters to Chicago in 1991. The city’s strong activist cohort that included physicians Young, Gordy Schiff, MD, and Claudia Fegan, MD, made the new home appealing.

Susan Rogers, MD, the immediate-past-president of PNHP, spent most of her clinical career as an internist at Stroger Hospital. She currently serves on the faculty of Rush University and its medical school admissions committee.

Rogers grew up in Hyde Park “which was so totally integrated, I never knew there were all-White or all-Black neighborhoods,” she says. 

In 7th grade, her mother took her and her two siblings to march with Martin Luther King, Jr., to protest school segregation. “It was then I realized how awful things were. My mother was pushing this, so I thought, this must be important.” At the brand-new Kenwood High School, as the Vietnam War was escalating, “that’s when I had a sense of using my voice to protest for change.”

As a Black student at the small western college that Rogers first attended, she “wasn’t exactly welcomed,” so she returned to Chicago to study biology at Roosevelt University. Unsure of whether she wanted to be a teacher, nurse, or doctor, she went on to graduate from medical school at the University of Illinois. 

Rogers loved being an attending at Stroger Hospital. “I went to County to take care of Black people. That is part of my activism.”

Educating doctors in activism

Now, Rogers and the Rush admissions committee look for a wide array of applicants. Some of them have volunteered locally or globally, and many are attracted to Rush because of its affiliation with Stroger Hospital. 

That said, Rogers notes the lack of Black physicians in the U.S., which correlates with the demographics of medical school applicants. Per Rogers, most applicants come from families with incomes in the top 20%, and many are children of physicians. 

Rogers attributes much of the inequality in health outcomes to income inequality and to institutionalized racism. 

“Because this country is so segregated, people don’t grow up really knowing people who did not grow up like them,” she says.

Philip Verhoef, MD, PhD, succeeded Rogers as PNHP’s president. His activism began during his training as a pediatrics resident at the University of California-Los Angeles, where he became involved with Doctors for America, a nonprofit dedicated to improving healthcare access.

Verhoef moved to Chicago to get additional training in critical care at the University of Chicago Medicine. “That is really when I became activated in the single-payer movement. PNHP was based in Chicago, and there were a lot of activists,” he says.

Now, though, Verhoef says he understands why younger physicians might avoid activism. Sometimes saddled with hundreds of thousands of dollars of debt, just starting their practices or families, they have neither time nor energy for activism. That lack of resources also applies to physicians on the front lines of inequity in emergency rooms, trauma centers, and safety-net hospitals.

While an event sparks some physicians into activism — such as the Flint, Michigan water crisis, exposed by a pediatrician — Verhoef sees himself as an educator for activists, through his role with PNHP. “Students don’t know the system they’re getting into.”

Like Ansell, Verhoef says that activism requires a certain skill set. “Let’s teach [doctors] how to be an activist, not just an advocate, because it’s part of your professional identity. 

We are at the top of the food chain, and people listen to us.” 

The medical residents and fellows at Northwestern University’s Feinberg School of Medicine experienced just how powerful their voices can be when they secured unionization. 

Verhoef says he sees clear benefits in their action. “We built many of our hospitals to function on the backs of resident labor, ripe for exploitation. Why do we work as much as we do and have no say in this process?”

Yet, he says, there’s more work ahead. “We need to start using our voices to get the healthcare we want and deserve in this country. That is our moral obligation as healthcare professionals.”

More physicians than ever, it seems, are doing exactly that.

https://chicagohealthonline.com…

May Day 2028 National Strike: Focus on Medicare for All

Prominent labor leader Shawn Fain has proposed a national strike of unionized workers four years from now, to highlight and advance the needs of workers and their families. This riveting vision will be super-charged with a focus on unified public funding of health care.

The UAW’S 2028 National Strike Should Center Medicare for All, JACOBIN, March 31, 2024, by Jonathan Michels & Will Cox

United Auto Workers president Shawn Fain has called on unions to come together for a national strike on International Workers Day, May 1, 2028. This is a radical idea – and elevating Medicare for All as a central demand would give workers across sectors a reason to join in.

Shawn Fain’s call to utilize labor power – four hundred thousand working members and six hundred thousand retirees make up the UAW alone – for the “good of the entire working class” is a major departure from business-as-usual unionism and represents a potential game changer for social movements to secure public goods, including Medicare for All, that extend beyond the shop floor.

The struggle for single-payer health care is part of a larger conflict between the working class and the billionaire class. Incremental reforms have gotten the single-payer movement nowhere, while legislative lobbying has proved insufficient. Nothing short of a nationwide campaign of rank-and-file workers – union and nonunion alike – willing to confront capital will be strong enough to secure transformative health reform.

In order to win, single-payer activists must embrace this once-in-a-generation opportunity and join in solidarity with workers in ways many never have before.

A general strike as envisioned by the UAW will take cooperation from other unions willing to align their contract expiration dates with April 30, 2028.

Fain frames workers as warriors locked in a struggle against the billionaire class, with economic equality and security for the working class hanging in the balance. This kind of class rhetoric shows an understanding among UAW leadership that there are some issues, such as the financing of high-quality health care, that are too burdensome for any one union to reasonably carry alone. Though it is still too early to tell, we could be witnessing union officials taking the first steps away from maintaining private welfare states for members and toward securing social goods for the benefit of all.

Of all the social reforms before the American public today, single payer is not only the most popular – a 2020 Fox News exit poll showed a staggering 72 percent of Americans want publicly funded health care – it also has the potential to be the most transformative.

Meanwhile, the only effective path to winning a transformative national health program is through our collective labor power. Any movement of workers willing to connect their struggle to a larger class struggle, and especially the struggle for single payer, is imperative.

There doesn’t need to be a general strike in 2028 to build the kind of worker-led movements in the United States that shook the halls of power even before unions were officially made legal. It is the process of organizing and building solidarity that is much more important than the turn out for a single event, march, or rally.

In order to win public goods, the union movement will have to become a mass movement.

The Medicare for All movement will need union and nonunion workers to build class-conscious organizing committees that draw strength and inspiration from unions, and that carry their fight into the community.

The starting point is when workers become aware that their interests are opposed to their bosses’ interests – and this should also frame how people organize for a universal national health program. Likewise, single-payer activists need to frame their fight as a class-conscious struggle. It’s going to affect all of us, so it’s going to take workers from every sector – from the factory worker to the academic, from physicians to food service workers.

You need a broad social coalition and labor needs to be out front.

Solidarity is not reading the news and telling your friend, “I hope the workers win.” It’s putting yourself on the line. The defining feature of the working class is that they must sell their labor in order to survive. That describes almost all of us.

Whether on a picket line or at a rally, it is imperative that single-payer advocates plug into rank-and-file organizing campaigns and make themselves available. We should see clinicians in white coats and nurses and health care workers in scrubs standing shoulder-to-shoulder with sanitation workers, autoworkers, and teachers. Anywhere workers are standing up, single-payer supporters should be there, too.

Only then will it become clear that we are part of the same struggle.

Comment:

By Don McCanne, M.D.

How long have we been doing this? (a long time)

How close are we to our goal? (not very close at all)

Do we anticipate a legislative solution? (not soon, but we should forge ahead anyway)

Do people want something done with our health care system?

There does seem to be wide agreement that our system is not working as it should be. Medical debt is a major problem faced not only by the uninsured but also by the insured who have difficulty paying premiums, deductibles, copayments, and disallowed charges. People frequently find that they cannot afford the care or medications they need.

People do not oppose government participation in health care since many enroll in Medicare, Medicaid, VA health, and other government programs as appropriate. Polls indicate support for publicly funded programs. Politicians promote government programs. Biden is supporting the ACA plans, and Trump is supporting government plans “better than Obamacare” though he hasn’t stated what that would be.

The point is that when the public realizes that we can have a plan that will ensure access to health care for everyone while keeping it affordable for everyone, eradicating the problem of medical debt, maybe it is time for mass public action. The JACOBIN article suggests a date of May 1, 2028 (and it is well worth reading the fairly long article in its entirety), but actually the organizing can begin right now.

Yes, there is a political divide in our nation. But the divide here is not so much left and right as it is all of us workers on all levels and the billionaires. We want health care for all the people, and, yes, we’ll include the billionaires.

https://healthjusticemonitor.org…

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