PNHP

How much does defensive medicine waste?

How much does defensive medicine waste?

Low Costs Of Defensive Medicine, Small Savings From Tort Reform

By J. William Thomas, Erika C. Ziller and Deborah A. Thayer
Health Affairs
September 2010
In this paper we present the costs of defensive medicine in thirty-five clinical specialties to determine whether malpractice liability reforms would greatly reduce health care costs. Defensive medicine includes tests and procedures ordered by physicians principally to reduce perceived threats of medical malpractice liability. The practice is commonly assumed to increase health care costs.
Across all specialties, reductions in medical malpractice premiums would lead to statistically significant savings in 2.0 percent of the conditions analyzed, but these are high-volume situations, comprising 35.8 percent of all episodes. However, the magnitude of savings that could be realized is small, accounting for less than 1 percent of medical care costs in every specialty. Across all thirty-five specialties, savings associated with a 10 percent premium reduction in medical malpractice premiums would be just 0.132 percent. Even if medical malpractice premiums were to be reduced as much as 30 percent, defensive medicine costs would decline no more than 0.4 percent.
http://content.healthaffairs.org/cgi/content/full/29/9/1578

Will bringing an end to defensive medicine reduce our national health expenditures? According to this and other studies, yes, but not by much.
Defensive medicine represents those tests and procedures that physicians order for the purpose of reducing the risk of medical malpractice liability. These are not random tests, but they are tests selected to prevent the patient from suffering harm – an essential component of malpractice.
If there were no liability exposure, why would a physician decide against ordering a test that might prevent a harmful outcome for the patient? Do physicians really believe that it is acceptable to gamble with the health of the patient by omitting potentially beneficial tests, yet is is not acceptable to place that same bet if a malpractice suit might ensue? Are these tests really for the benefit of the doctor and not for the benefit of the patient?
How often have you heard a physician confess to ordering a test that the patient didn’t need, but the test was still necessary to prevent a lawsuit? That is a non sequitur. If the physician could be sued for not ordering the test, then the test was absolutely essential.
The point of today’s message is that we keep looking in the wrong places for ways to try to control health care spending. Though we need malpractice reform for other reasons, we can’t look at it as a source of significant health care savings.
The most important first step to begin to control runaway health care costs would be to replace our wasteful, dysfunctional health care financing system with a single payer national health program – an improved Medicare for everyone – a Medicare that provides us with the financial tools with which we could slow the rate of health care spending increases.

Mad Docs planning California road trip

By Bennett Hall, Corvallis (Ore.) Gazette Times, Sept. 8, 2010

The Mad as Hell Doctors are at it again.

The loose-knit group of Oregon physicians who barnstormed the country last fall to promote a national health plan are planning another road trip, this time to California instead of Washington, D.C.

Although they fell short last year in their bid to push the single-payer system to the forefront of the national health care reform debate, the Mad Docs haven’t given up. At this point, they believe, state-level reforms may offer the best hope for keeping their dreams of universal government-sponsored health coverage alive, and they hope to introduce a single-payer bill in the Oregon Legislature next year.

In the meantime, though, they see California as a key battleground for the issue.

“California’s ahead of the rest of the states, but there’s more than a dozen that are formulating their own bills as we speak,” said Mike Huntington, a retired radiation oncologist and one of two Corvallis physicians involved in organizing the Mad as Hell Doctors.

“I don’t have any delusion that anything Mike and I do, in the short run, is going to result in any policy change — we’re not that delusional,” added his partner, Paul Hochfeld, an emergency room physician at Good Samaritan Regional Medical Center.

“But we do think we need to tell people the truth about our sick-care non-system: It’s not working.”

California Senate Bill 810, which would create a single, government-run medical plan, has twice passed the Legislature only to be vetoed by the governor. The bill passed the state Senate again this year, only to be bottled up in the lower chamber.

In order to support their allies in the Golden State — and to keep the idea of a single-payer plan alive for the next legislative session — the Mad as Hell Doctors are planning a 23-city California tour. They’ll leave Oregon on Sept. 22, hold their first rally in Arcata on the 23rd and wrap up their trip in Sacramento on Oct. 12.

They’ll travel in a “care-a-van” of three minivans emblazoned with the Mad as Hell Doctors logo and slogans such as “Where the rubber gloves meet the road” and “Improved Medicare for All = single-payer health care.”

Hochfeld and Huntington expect to be part of a rotating group of activists averaging six to eight people during the trip.

Joining them for the whole ride will be Marc Sapir, a family practitioner from Berkeley, and Philip Kauffman, a grassroots organizer and single-payer activist from Portland.

Among those going part of the way will be Baltimore pediatrician Margaret Flowers, who plans to spend a week with the Mad Docs roadshow. Like Hochfeld and Huntington, Flowers is a member of Physicians for a National Health Program, a group of doctors pushing to replace America’s current hodgepodge of private and government insurance plans with a single tax-supported plan that covers everyone.

To set the stage for their California tour, the Mad Docs will hold a rally this Friday in Corvallis.

The event, which begins at 7 p.m. at the First Congregational Church, will feature a panel discussion on the state of the nation’s health care system and the potential benefits of switching to single-payer coverage.

In addition to Huntington, the speakers will include Dr. Cosimo Storniolo, a Samaritan Health Services internist; Dr. Sydney Piercey, a neurologist with The Corvallis Clinic; Dr. Norm Castillo, an independent family practitioner; and Caroline Zaworski, a nurse with the Samaritan Regional Cancer Center.

http://www.gazettetimes.com/news/local/article_2adfe8a6-bb10-11df-a2d7-001cc4c03286.html

Fiscal Commission wants price signals for Medicare?

About the National Commission on Fiscal Responsibility and Reform

Fiscal Commission.gov

President Obama created the bipartisan National Commission on Fiscal Responsibility and Reform to address our nation’s fiscal challenges. The Commission is charged with identifying policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability over the long run. Specifically, the Commission shall propose recommendations designed to balance the budget, excluding interest payments on the debt, by 2015. In addition, the Commission shall propose recommendations that meaningfully improve the long-run fiscal outlook, including changes to address the growth of entitlement spending and the gap between the projected revenues and expenditures of the Federal Government.

The Commission will meet as a whole once a month while Congress is in session. The Commission will vote on a final report containing a set of recommendations to achieve its mission no later than December 1, 2010. The final report will require the approval of at least 14 of the Commission’s 18 members.

http://www.fiscalcommission.gov/about

And…

Republicans Dominate Medicare Discussions On White House Fiscal Commission

By Brian Beutler
TPM
September 9, 2010

The White House’s fiscal commission has become a target for progressive activists in large part because a number of reports and public statements indicate that the panel will recommend benefit cuts to Social Security.

But the commissioners are also grappling with another sensitive entitlement program: Medicare. For a number of reasons, the commission is farther from consensus on Medicare than it is on Social Security. But the ideological conservatism of the Republicans on the commission — and, indeed, of the commission as a whole — combined with Democratic fatigue over health care reform mean that the center of gravity of discussions is tilted to the right.

“[B]asically you’ve got some Dems saying they don’t want to jump back in the [health care reform] pool, so you’ve mainly got Republicans swimming in there on their own,” says one source familiar with the commission’s proceedings.

“There have been some discussions about cost-sharing. There have been some discussions about Medi-gap policies,” the source says.

At a staff level, this source says, the feeling is that “there needs to be more skin in the game and people need to pay more…the whole argument that people don’t understand how much health care costs and are wasteful.”

“A lot of discussion on the commission has been that people need to get better price signals and be smarter shoppers,” the second source said. “And that is very, very worrisome.”

http://tpmdc.talkingpointsmemo.com/2010/09/republicans-dominate-medicare-discussions-on-white-house-fiscal-commission.php?ref=fpblg

Comment: 

By Don McCanne, MD

Apparently President Obama’s National Commission on Fiscal Responsibility and Reform is considering changes to Medicare that would make beneficiaries “smarter shoppers” by adopting innovations that would require them to pay more out of pocket for health care.

Considerations include reducing or eliminating Medi-gap policies, increasing deductibles and coinsurance, and using vouchers that would establish financial incentives to choose more Spartan private plans.

Although the commission theoretically is politically balanced, all of the Republican members are right-wing conservatives, and the Democrats are split between progressives and deficit hawks who would rather reduce government spending than increase tax revenues. If you check the list of commission members (available at the fiscal commission link above) it is difficult to identify with certainty the five members necessary to block these deleterious “consumer-directed” policies.

Single payer supporters are already finding some resistance from colleagues to the “Medicare for all” label, especially with the continued failure to resolve the SGR (sustainable growth rate) issue. Although we speak of an “improved” Medicare, that distinction is not always clear and certainly would not mean much when holding up a further handicapped Medicare program as a model of reform.

Should the commission end up making these outrageous recommendations, hopefully the 310 million of us would respond by insisting that Medicare be protected and improved, as opposed to latching onto former Senator Alan Simpson’s infamous milk cow.

Fiscal Commission wants price signals for Medicare?

About the National Commission on Fiscal Responsibility and Reform

Fiscal Commission.gov
President Obama created the bipartisan National Commission on Fiscal Responsibility and Reform to address our nation’s fiscal challenges. The Commission is charged with identifying policies to improve the fiscal situation in the medium term and to achieve fiscal sustainability over the long run. Specifically, the Commission shall propose recommendations designed to balance the budget, excluding interest payments on the debt, by 2015. In addition, the Commission shall propose recommendations that meaningfully improve the long-run fiscal outlook, including changes to address the growth of entitlement spending and the gap between the projected revenues and expenditures of the Federal Government.
The Commission will meet as a whole once a month while Congress is in session. The Commission will vote on a final report containing a set of recommendations to achieve its mission no later than December 1, 2010. The final report will require the approval of at least 14 of the Commission’s 18 members.
http://www.fiscalcommission.gov/about

And…

Republicans Dominate Medicare Discussions On White House Fiscal Commission

By Brian Beutler
TPM
September 9, 2010
The White House’s fiscal commission has become a target for progressive activists in large part because a number of reports and public statements indicate that the panel will recommend benefit cuts to Social Security.
But the commissioners are also grappling with another sensitive entitlement program: Medicare. For a number of reasons, the commission is farther from consensus on Medicare than it is on Social Security. But the ideological conservatism of the Republicans on the commission — and, indeed, of the commission as a whole — combined with Democratic fatigue over health care reform mean that the center of gravity of discussions is tilted to the right.
“[B]asically you’ve got some Dems saying they don’t want to jump back in the [health care reform] pool, so you’ve mainly got Republicans swimming in there on their own,” says one source familiar with the commission’s proceedings.
“There have been some discussions about cost-sharing. There have been some discussions about Medi-gap policies,” the source says.
At a staff level, this source says, the feeling is that “there needs to be more skin in the game and people need to pay more…the whole argument that people don’t understand how much health care costs and are wasteful.”
“A lot of discussion on the commission has been that people need to get better price signals and be smarter shoppers,” the second source said. “And that is very, very worrisome.”
http://tpmdc.talkingpointsmemo.com/2010/09/republicans-dominate-medicare-discussions-on-white-house-fiscal-commission.php?ref=fpblg

Apparently President Obama’s National Commission on Fiscal Responsibility and Reform is considering changes to Medicare that would make beneficiaries “smarter shoppers” by adopting innovations that would require them to pay more out of pocket for health care.
Considerations include reducing or eliminating Medi-gap policies, increasing deductibles and coinsurance, and using vouchers that would establish financial incentives to choose more Spartan private plans.
Although the commission theoretically is politically balanced, all of the Republican members are right-wing conservatives, and the Democrats are split between progressives and deficit hawks who would rather reduce government spending than increase tax revenues. If you check the list of commission members (available at the fiscal commission link above) it is difficult to identify with certainty the five members necessary to block these deleterious “consumer-directed” policies.
Single payer supporters are already finding some resistance from colleagues to the “Medicare for all” label, especially with the continued failure to resolve the SGR (sustainable growth rate) issue. Although we speak of an “improved” Medicare, that distinction is not always clear and certainly would not mean much when holding up a further handicapped Medicare program as a model of reform.
Should the commission end up making these outrageous recommendations, hopefully the 310 million of us would respond by insisting that Medicare be protected and improved, as opposed to latching onto former Senator Alan Simpson’s infamous milk cow.

Is national health spending rising?

National Health Spending Projections: The Estimated Impact Of Reform Through 2019

By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens and Andrew J. Madison (from the CMS Office of the Actuary)
Health Affairs
September 9, 2010

Projected National Health Expenditures (NHE)

2010 – $2,600 billion (17.5% of GDP)
2019 – $4,571 billion (19.6% of GDP)

Conclusion

In this analysis, we have shown that the net impacts of key Affordable Care Act and other legislative provisions on total national health expenditures are moderate, but the underlying effects on payer spending levels and growth rates are much more pronounced and reflect the Affordable Care Act’s many substantive changes to health care coverage and financing. As the provisions are implemented over time, their actual impacts may well differ considerably from these estimates.

Many important details of the legislation will evolve through regulatory activity and become more concrete. Moreover, behavioral responses to reform provisions on the part of health care providers and consumers, employers, and insurers are difficult to anticipate. These will become more apparent only after the bulk of reforms have been implemented in 2014.

Report – free download for the next two weeks only:
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0788v1

Comment:

By Don McCanne, MD

What does this mean? Here are some of today’s headlines of articles covering this report:

Health Plan Won’t Fuel Big Spending, Report Says (New York Times)

Gov’t: Spending to rise under health care overhaul (Washington Post/AP)

Government Economists Say Health Overhaul Won’t Significantly Increase Spending (Kaiser Health News)

Health Outlays Still Seen Rising (Wall Street Journal)

Consumers to Pay Nine Percent More Out of Pocket (Fiscal Times)

Is health care spending rising or isn’t it? The confusion stems from the fact that the additional increase in projected national health expenditures (NHE) resulting from the enactment of the Patient Protection and Affordable Care Act (PPACA) is relatively modest when compared to the projection of NHE without enactment of PPACA. Without PPACA, NHE for 2019 was projected to be $4.48 trillion (19.3% 0f GDP), whereas now the projection is $4.57 trillion (19.6% of GDP).

Thus the conflicting reporting reflects the “I told you so” arguments on both sides. The opponents of PPACA are saying that the promises of lower costs are not true, and this is yet one more report that shows that costs will increase. The proponents of reform are saying that this report proves that many more individuals will be covered without a significant increase in costs. This is the wrong debate.

The fact is that national health expenditures had been predicted to increase at a rate well in excess of inflation, and that PPACA will do nothing to slow that increase, though it will not make it much worse. What PPACA is doing instead is that it is rearranging the financing of health care in a manner that will result in more Americans – but not all – having some sort of health care coverage, but it does so in a way that can have a significant negative impact on patients and providers.

How can so many more people be covered without spending much more money? There are some hints in this report.

“For example, higher projected spending by a greater number of insured people is somewhat offset by the projected impact of the Medicare savings provisions and relatively lower prices paid to providers for services to newly insured Medicaid beneficiaries.”

Providers will be paid significantly less for the large influx of Medicaid patients, because of the reductions in Medicare payments, and especially because of the reductions that will be dictated by the Independent Payment Advisory Board. This could be disruptive to the care provided by the physicians and hospitals that are targeted by these reductions.

” By 2018, however, we project out-of-pocket spending growth of 9.6 percent — four percentage points faster than our February 2010 projection. This effect is mainly attributable to the excise tax on high-cost employer-sponsored plans, which is expected to result in greater cost sharing as many affected employers scale back coverage to minimize their tax exposure.”

There are other measures in PPACA that will result in additional cost shifting to patients, such as the low actuarial value of the exchange plans with subsidies that are inadequate to prevent higher out-of-pocket spending. Making health care less affordable for those who need it does reduce spending, but at a terrible cost in impaired health outcomes.

Covering tens of millions more people for about the same spending, using our inefficient fragmented health care financing system, is being accomplished by making patients and their health care providers absorb the much higher costs. Just wait until we all feel the pain.

Is national health spending rising?

National Health Spending Projections: The Estimated Impact Of Reform Through 2019

By Andrea M. Sisko, Christopher J. Truffer, Sean P. Keehan, John A. Poisal, M. Kent Clemens and Andrew J. Madison (from the CMS Office of the Actuary)
Health Affairs
September 9, 2010
Projected National Health Expenditures (NHE)
2010 – $2,600 billion (17.5% of GDP)
2019 – $4,571 billion (19.6% of GDP)
Conclusion
In this analysis, we have shown that the net impacts of key Affordable Care Act and other legislative provisions on total national health expenditures are moderate, but the underlying effects on payer spending levels and growth rates are much more pronounced and reflect the Affordable Care Act’s many substantive changes to health care coverage and financing. As the provisions are implemented over time, their actual impacts may well differ considerably from these estimates.
Many important details of the legislation will evolve through regulatory activity and become more concrete. Moreover, behavioral responses to reform provisions on the part of health care providers and consumers, employers, and insurers are difficult to anticipate. These will become more apparent only after the bulk of reforms have been implemented in 2014.
Report – free download for the next two weeks only:
http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0788v1

What does this mean? Here are some of today’s headlines of articles covering this report:
Health Plan Won’t Fuel Big Spending, Report Says (New York Times)
Gov’t: Spending to rise under health care overhaul (Washington Post/AP)
Government Economists Say Health Overhaul Won’t Significantly Increase Spending (Kaiser Health News)
Health Outlays Still Seen Rising (Wall Street Journal)
Consumers to Pay Nine Percent More Out of Pocket (Fiscal Times)
Is health care spending rising or isn’t it? The confusion stems from the fact that the additional increase in projected national health expenditures (NHE) resulting from the enactment of the Patient Protection and Affordable Care Act (PPACA) is relatively modest when compared to the projection of NHE without enactment of PPACA. Without PPACA, NHE for 2019 was projected to be $4.48 trillion (19.3% 0f GDP), whereas now the projection is $4.57 trillion (19.6% of GDP).
Thus the conflicting reporting reflects the “I told you so” arguments on both sides. The opponents of PPACA are saying that the promises of lower costs are not true, and this is yet one more report that shows that costs will increase. The proponents of reform are saying that this report proves that many more individuals will be covered without a significant increase in costs. This is the wrong debate.
The fact is that national health expenditures had been predicted to increase at a rate well in excess of inflation, and that PPACA will do nothing to slow that increase, though it will not make it much worse. What PPACA is doing instead is that it is rearranging the financing of health care in a manner that will result in more Americans – but not all – having some sort of health care coverage, but it does so in a way that can have a significant negative impact on patients and providers.
How can so many more people be covered without spending much more money? There are some hints in this report.
“For example, higher projected spending by a greater number of insured people is somewhat offset by the projected impact of the Medicare savings provisions and relatively lower prices paid to providers for services to newly insured Medicaid beneficiaries.”
Providers will be paid significantly less for the large influx of Medicaid patients, because of the reductions in Medicare payments, and especially because of the reductions that will be dictated by the Independent Payment Advisory Board. This could be disruptive to the care provided by the physicians and hospitals that are targeted by these reductions.
” By 2018, however, we project out-of-pocket spending growth of 9.6 percent — four percentage points faster than our February 2010 projection. This effect is mainly attributable to the excise tax on high-cost employer-sponsored plans, which is expected to result in greater cost sharing as many affected employers scale back coverage to minimize their tax exposure.”
There are other measures in PPACA that will result in additional cost shifting to patients, such as the low actuarial value of the exchange plans with subsidies that are inadequate to prevent higher out-of-pocket spending. Making health care less affordable for those who need it does reduce spending, but at a terrible cost in impaired health outcomes.
Covering tens of millions more people for about the same spending, using our inefficient fragmented health care financing system, is being accomplished by making patients and their health care providers absorb the much higher costs. Just wait until we all feel the pain.

A special message from Senator Mark Leno on SB 810, the California Universal Health Care Act

September 3, 2010

Dear Friends,

By now most of you have heard the disappointing news that our bill, SB 810, the California Universal Health Care Act, was held on the Assembly Floor on the last night of session, effectively killing the measure until next year. Over my strong objections, Assembly leadership decided to hold the bill. Although we are greatly disappointed, we are determined to come back even stronger next year.

I want to thank and recognize the work of the California School Employees Association and California Nurses Association who worked hard to lobby members all year. I also want to recognize Health Care for All, California Physicians for a National Health Plan, Single Payer Now, California Alliance for Retired Americans, California Health Professional Student Alliance, League of Women Voters and the other dozen organizational members of our statewide alliance. Most importantly, I thank the thousands of advocates who made phone calls, requested meetings, attended rallies, and sent letters, faxes and emails, making it clear to legislators that the single payer health care movement is vibrant, strong and growing larger every day.

Our movement has always acknowledged that it is founded on a long-term vision and strategy. This setback does not change our work, it only emboldens it. For decades we have found the courage to speak out for single payer, even when others around us told us that now is not the right time. We have learned that fear and hesitation can only be overcome by courage and commitment – something with which our movement is rich. That is how we have come so far, and that is why we will win.

Without question, I commit to reintroducing this bill again next year, and to work ever harder with you to achieve the only real solution to our health care crisis – Medicare for All.

I encourage you to begin our work today to ensure the passage of this bill next session. Now is the time to educate your current representatives, and those who are seeking office, about the need for single payer universal health care and to ask for their support. More importantly, now is the time for you to educate your co-workers, neighbors, friends, and family members about why their elected officials should take a strong stance in support of Medicare for All.

We’ve always said that the closer we come, the harder our work will become. So often, it’s “two steps forward, one step back.” Let this temporary detour enliven us to work even harder to see single payer become a reality in California. With term limits, it is clear that each new class of representatives needs to be educated and reminded of how important this issue is to our state. Next year will bring a new governor and a new legislature – and consequently, new opportunities and challenges. To win, we must come closer together as allies, fight smarter, and work even harder.

As the author of SB 810, I believe deeply in you, this cause and this movement. Until every Californian has health care and no family faces medical bankruptcy, we will not be deterred. Until our state budget and entire economy are no longer being swallowed by health care costs, we will not cease. Until we have “Medicare for All,” we will not stop fighting. We’re the fastest growing grassroots movement in America, and we will win universal health care. Let’s dig deep, redouble our efforts and get back to work.

Sincerely,

Senator Mark Leno

http://senweb03.senate.ca.gov/focus/outreach/sd03/sd03-ealert-20100902.asp

PacifiCare violated state law nearly 1 million times

California regulators seek up to $9.9 billion in fines from PacifiCare

By Duke Helfand
Los Angeles Times
September 7, 2010

California regulators are seeking fines of up to $9.9 billion from health insurer PacifiCare over allegations that it repeatedly mismanaged medical claims, lost thousands of patient documents, failed to pay doctors what they were owed and ignored calls to fix the problems.

In court filings and other documents, the California Department of Insurance says PacifiCare violated state law nearly 1 million times from 2006 to 2008 after it was purchased by UnitedHealth Group Inc., the nation’s largest health insurance company by revenue.

“This is about intentional disregard for the interests of doctors, hospitals and patients in California, and the pursuit of cutting costs at any means possible,” said Adam Cole, the insurance department’s general counsel. “It’s a story of intense corporate greed.”

http://www.latimes.com/health/la-fi-pacificare-unitedhealth-20100908,0,6657147.story

Comment: 

By Don McCanne, MD

The largest health insurer in the nation (in terms of revenue), UnitedHealth Group, through UnitedHealthcare’s subsidiary – PacifiCare, violated California state insurance laws nearly a million times! This is the industry that the Patient Protection and Affordable Care Act was designed to protect instead of replacing, even though that meant that not everyone would be insured and many more would be underinsured. This was a trade-off that resulted in a loss on both ends.

This is more than the gross incompetence of an insurer that has failed to provide the excessive administrative services for which we are being gouged involuntarily. As the insurance department’s general counsel said, “It’s a story of intense corporate greed.”

It’s time to throw these incompetent thieves out, fix Medicare, and then provide it for everyone.

PacifiCare violated state law nearly 1 million times

California regulators seek up to $9.9 billion in fines from PacifiCare

By Duke Helfand
Los Angeles Times
September 7, 2010
California regulators are seeking fines of up to $9.9 billion from health insurer PacifiCare over allegations that it repeatedly mismanaged medical claims, lost thousands of patient documents, failed to pay doctors what they were owed and ignored calls to fix the problems.
In court filings and other documents, the California Department of Insurance says PacifiCare violated state law nearly 1 million times from 2006 to 2008 after it was purchased by UnitedHealth Group Inc., the nation’s largest health insurance company by revenue.
“This is about intentional disregard for the interests of doctors, hospitals and patients in California, and the pursuit of cutting costs at any means possible,” said Adam Cole, the insurance department’s general counsel. “It’s a story of intense corporate greed.”
http://www.latimes.com/health/la-fi-pacificare-unitedhealth-20100908,0,6657147.story

The largest health insurer in the nation (in terms of revenue), UnitedHealth Group, through UnitedHealthcare’s subsidiary – PacifiCare, violated California state insurance laws nearly a million times! This is the industry that the Patient Protection and Affordable Care Act was designed to protect instead of replacing, even though that meant that not everyone would be insured and many more would be underinsured. This was a trade-off that resulted in a loss on both ends.
This is more than the gross incompetence of an insurer that has failed to provide the excessive administrative services for which we are being gouged involuntarily. As the insurance department’s general counsel said, “It’s a story of intense corporate greed.”
It’s time to throw these incompetent thieves out, fix Medicare, and then provide it for everyone.

Healthcare reforms don't go far enough

Many people are being forced into a tradeoff as insurance rates continue to rise

By David Lazarus, Los Angeles Times, Sept. 7, 2010

Ruta Vaisnys just got the word from Blue Shield of California: Her monthly health insurance premium will rise by more than 28 percent to $243 beginning next month.

The Silver Lake resident is among the 150,000 Blue Shield customers with individual insurance policies who will experience yet another rate hike Oct. 1. An additional 180,000 Blue Shield members will see their rates go up by an average of 18.3 percent over the next year.

Meanwhile, about 800,000 Anthem Blue Cross individual policyholders will see their premiums rise by an average of 14 percent.

“Your rate is rising for a variety of reasons, all associated with the rapidly increasing cost of medical care,” Vaisnys and other Blue Shield customers are being told by letter.

“Your individual rate reflects a combination of what Blue Shield pays for healthcare, as well as factors that are specific to you – in particular, the product you purchased and your age.”

That may be true. But it also reflects a healthcare system so wildly out of whack that adequate insurance is quickly growing out of reach for all but the wealthiest Americans.

And with coverage remaining primarily in the hands of the private sector, it’s unlikely prices will come down significantly even when the bulk of pending healthcare reforms take effect four years from now. At that time, individual policies will be offered through “exchanges” intended to promote competition.

“We’re losing money on individual policies right now,” said Tom Epstein, a Blue Shield spokesman. “We’ll definitely need to make some money in the exchange.”

Vaisnys’ situation highlights what millions of Americans are now facing.

I first wrote about her in June 2009, after Blue Shield had informed her that her monthly premium was about to soar 54 percent. That included a 28 percent increase that the insurer said reflected its higher costs, as well as an additional 26 percent increase because Vaisnys was about to turn 45.

As I noted at the time, Vaisnys (she went by Miller then, prior to a divorce) was in great health. She worked as an actress. She ate well. She exercised regularly. She didn’t smoke. Her turning 45 was nothing more than an arbitrary blip on the calendar.

Vaisnys is now 46. She attends ballet classes three times a week. She does Pilates. She’s as healthy as ever.

“I have very low blood pressure,” Vaisnys told me after learning of Blue Shield’s latest rate hike. “But I think they’re trying to give me a stroke.

“It makes me angry that they keep doing this year after year,” she said. “I feel so powerless.”

Since we’d last spoken, Vaisnys had switched Blue Shield insurance policies. To lower her monthly premium, she boosted her annual deductible to $3,500 from $2,400.

In other words, she’s had to accept less coverage to keep her insurance costs manageable. And she’s not alone.

A recent survey by the Kaiser Family Foundation found that 16 percent of individual policyholders nationwide have switched to less-comprehensive plans to keep costs down. A quarter of individual policyholders now have an annual deductible of $5,000 or more.

Yet Blue Shield’s Epstein insisted that the company loses money on its individual policies because state regulators won’t let it raise rates high enough to cover the full cost of hospital stays, doctor visits and prescription drugs.

“There needs to be a significant transformation of how medical care is delivered,” he said.

I agree. And while I support the changes that President Obama and Democratic lawmakers have engineered, they don’t go nearly far enough.

The healthcare reforms place a new emphasis on wellness programs, but this needs to be built into the pricing of hospital and doctor reimbursements. Simply put, doctors and medical facilities should have financial incentives from insurers for keeping people healthy, not just for treating them when they get sick.

And it seems increasingly clear that insurance exchanges and mandates won’t do much to lower medical costs or guarantee adequate coverage to all. Most likely, we’ll see insurers vying to offer the most bare-bones policies at the highest prices they can get away with.

Some sort of Medicare-for-all program remains the only equitable way that every American can be provided with adequate and affordable coverage. This wouldn’t be socialized medicine and it wouldn’t be state-run healthcare.

It would be an extension of a social safety net that already exists to prevent millions of people from being denied needed healthcare. Why so many conservatives feel threatened by such an idea is beyond me.

In the meantime, insurance costs will continue rising. Epstein said he expects average annual rate hikes for individual policyholders to remain “in the high teens” for the foreseeable future.

I asked Vaisnys if she’s hopeful her costs will go down once the healthcare reforms kick in.

“I’m not holding my breath,” she replied.

She said her plan is basically not to ever get sick.

You’d think we could do better than that.

latimes.com/health/healthcare/la-fi-lazarus-20100907,0,5223381.column

Healthcare reforms don’t go far enough

Many people are being forced into a tradeoff as insurance rates continue to rise

By David Lazarus, Los Angeles Times, Sept. 7, 2010

Ruta Vaisnys just got the word from Blue Shield of California: Her monthly health insurance premium will rise by more than 28 percent to $243 beginning next month.

The Silver Lake resident is among the 150,000 Blue Shield customers with individual insurance policies who will experience yet another rate hike Oct. 1. An additional 180,000 Blue Shield members will see their rates go up by an average of 18.3 percent over the next year.

Meanwhile, about 800,000 Anthem Blue Cross individual policyholders will see their premiums rise by an average of 14 percent.

“Your rate is rising for a variety of reasons, all associated with the rapidly increasing cost of medical care,” Vaisnys and other Blue Shield customers are being told by letter.

“Your individual rate reflects a combination of what Blue Shield pays for healthcare, as well as factors that are specific to you – in particular, the product you purchased and your age.”

That may be true. But it also reflects a healthcare system so wildly out of whack that adequate insurance is quickly growing out of reach for all but the wealthiest Americans.

And with coverage remaining primarily in the hands of the private sector, it’s unlikely prices will come down significantly even when the bulk of pending healthcare reforms take effect four years from now. At that time, individual policies will be offered through “exchanges” intended to promote competition.

“We’re losing money on individual policies right now,” said Tom Epstein, a Blue Shield spokesman. “We’ll definitely need to make some money in the exchange.”

Vaisnys’ situation highlights what millions of Americans are now facing.

I first wrote about her in June 2009, after Blue Shield had informed her that her monthly premium was about to soar 54 percent. That included a 28 percent increase that the insurer said reflected its higher costs, as well as an additional 26 percent increase because Vaisnys was about to turn 45.

As I noted at the time, Vaisnys (she went by Miller then, prior to a divorce) was in great health. She worked as an actress. She ate well. She exercised regularly. She didn’t smoke. Her turning 45 was nothing more than an arbitrary blip on the calendar.

Vaisnys is now 46. She attends ballet classes three times a week. She does Pilates. She’s as healthy as ever.

“I have very low blood pressure,” Vaisnys told me after learning of Blue Shield’s latest rate hike. “But I think they’re trying to give me a stroke.

“It makes me angry that they keep doing this year after year,” she said. “I feel so powerless.”

Since we’d last spoken, Vaisnys had switched Blue Shield insurance policies. To lower her monthly premium, she boosted her annual deductible to $3,500 from $2,400.

In other words, she’s had to accept less coverage to keep her insurance costs manageable. And she’s not alone.

A recent survey by the Kaiser Family Foundation found that 16 percent of individual policyholders nationwide have switched to less-comprehensive plans to keep costs down. A quarter of individual policyholders now have an annual deductible of $5,000 or more.

Yet Blue Shield’s Epstein insisted that the company loses money on its individual policies because state regulators won’t let it raise rates high enough to cover the full cost of hospital stays, doctor visits and prescription drugs.

“There needs to be a significant transformation of how medical care is delivered,” he said.

I agree. And while I support the changes that President Obama and Democratic lawmakers have engineered, they don’t go nearly far enough.

The healthcare reforms place a new emphasis on wellness programs, but this needs to be built into the pricing of hospital and doctor reimbursements. Simply put, doctors and medical facilities should have financial incentives from insurers for keeping people healthy, not just for treating them when they get sick.

And it seems increasingly clear that insurance exchanges and mandates won’t do much to lower medical costs or guarantee adequate coverage to all. Most likely, we’ll see insurers vying to offer the most bare-bones policies at the highest prices they can get away with.

Some sort of Medicare-for-all program remains the only equitable way that every American can be provided with adequate and affordable coverage. This wouldn’t be socialized medicine and it wouldn’t be state-run healthcare.

It would be an extension of a social safety net that already exists to prevent millions of people from being denied needed healthcare. Why so many conservatives feel threatened by such an idea is beyond me.

In the meantime, insurance costs will continue rising. Epstein said he expects average annual rate hikes for individual policyholders to remain “in the high teens” for the foreseeable future.

I asked Vaisnys if she’s hopeful her costs will go down once the healthcare reforms kick in.

“I’m not holding my breath,” she replied.

She said her plan is basically not to ever get sick.

You’d think we could do better than that.

latimes.com/health/healthcare/la-fi-lazarus-20100907,0,5223381.column

Is primary care relinquishing acute care?

Where Americans Get Acute Care: Increasingly, It’s Not At Their Doctor’s Office

By Stephen R. Pitts, Emily R. Carrier, Eugene C. Rich and Arthur L. Kellermann
Health Affairs
September 2010

Abstract
 
Historically, general practitioners provided first-contact care in the United States. Today, however, only 42 percent of the 354 million annual visits for acute care — treatment for newly arising health problems — are made to patients’ personal physicians. The rest are made to emergency departments (28 percent), specialists (20 percent), or outpatient departments (7 percent). Although fewer than 5 percent of doctors are emergency physicians, they handle a quarter of all acute care encounters and more than half of such visits by the uninsured. Health reform provisions in the Patient Protection and Affordable Care Act that advance patient-centered medical homes and accountable care organizations are intended to improve access to acute care. The challenge for reform will be to succeed in the current, complex acute care landscape.

http://content.healthaffairs.org/cgi/content/abstract/29/9/1620

Comment: 

By Don McCanne, MD

When you say “my physician,” what do you mean? For most of us, that means the physician whom you call when you have a medical need. It’s the physician who will always be there for you, or who will at least ensure that a colleague is available when taking an off-call breather or when on vacation. Yet, as this study shows, personal physicians or their associates provide care for only 42 percent of acute problems. Increasingly, patients can no longer rely on their doctor’s office when they need acute care.

The policy community certainly recognizes the crisis in primary care. Much attention has been directed toward improving chronic care management within the primary care environment. Unfortunately, much of these efforts remain in the discussion phases, and only limited improvement has been made in the application of these relatively imprecisely defined concepts.

Yet what the primary care professional should be really good at – timely care of acute problems – has been almost completely ignored by the policy community. Physicians are too busy and don’t have time to take care of their patients. (Although that thought certainly can be expanded upon, the irony is inescapable.)

What are some of the solutions?

*  Emergency departments (EDs) already are bearing the largest portion of the overload. Queues in EDs are enough of a problem without adding to the waiting room backlog of many individuals who would be more appropriately cared for in a less intensive environment, such as a primary care practice. Adding to the problems with our overcrowded EDs is the burden of having to care for over one-half of all uninsured individuals with acute care problems.

*  Patients in the next largest sector directly access specialists for their acute problems. Sometimes this may be quite appropriate, yet many times it may result in more expensive care for problems that would be more appropriately managed in a less expensive primary care environment. Also some patients who should be cared for by specialists may not be able to access them for several reasons, and, once again, the primary care physician would be in a better position to enable that access for the patient.

*  Outpatient departments of integrated health systems appropriately may fulfill the role as the acute care provider as long as arrangements are made for access outside of clinic hours. These departments are usually associated with larger institutions, and, as such, would never be much more than a niche provider of acute care services.

*  Retail clinics are capable of providing only the most basic of acute care services, and further fragment the coordinated care that should be provided in the primary care environment. Further, retail clinics skim off the easy, cash paying “customers” (a more appropriate term than “patients” in this retail environment). The same is true of urgent care centers and their customers, though they are usually capable of caring for a greater variety of problems.

*  Concierge physicians do provide greater personal attention, but for very high fees that most of us cannot afford. To provide this higher level of accessibility, they sharply reduce the number of patients in their practices, further compounding the problem of the critical shortage of primary care physicians.

*  Community health centers (CHCs) fulfill an important role in primary care, especially because they usually provide access for underserved patients in underserved communities. They provide acute care services during clinic hours, though patients often must rely on EDs when the clinics are closed. Most CHCs continue to struggle with finances. Also, most have difficulties in obtaining the cooperation of an adequate variety of specialists in providing care for more complex problems.

Members of Congress are quite aware of the profound deficiencies in our primary care infrastructure, so they included some measures in the Patient Protection and Affordable Care Act (PPACA) designed to address this issue. Will they help?

Funds are being allocated for primary care training programs. That is certainly a step in the right direction, but the funds are quite limited and will hardly make a dent in the problem.

More funds are being allocated for community health centers, again certainly a beneficial measure, but one which falls far short of meeting the need.

Some Medicare funds are being shifted from other services to primary care but not enough to even begin to narrow the compensation gap between primary care and the surgical specialists. Why would medical students, saddled with education debt, choose primary care with its long hours and modest pay, when specialties promise higher pay and more free time?

PPACA contains measures to promote the medical home model – theoretically the ideal primary care model. Although medical home demonstration projects are under way, it will be a long time before the specifics of the model will be precisely defined and ready for universal application. Further, the logistics of permeating the nation with medical homes may be beyond the capabilities of our public and private stewards working within the limitations of our dysfunctional financing system. Though the medical home model shows great promise, we need a financing system that will make it much more feasible.

The great hope of PPACA has been pinned on accountable care organizations (ACOs). This Health Affairs article defines ACOs as “integrated or virtually integrated delivery systems that will provide care for a defined population in a range of settings, linked by health information technology.” The supporters of ACOs have described everything from full service integrated health care delivery systems to “virtual” systems that are not connected by much more than an information technology system.

Although the providers of health care may seek to create innovative ACO systems that theoretically would improve patient care, it is likely that the emphasis will be on, not just controlling, but actually reducing spending. The ghost of managed care past will be embellished through the “integrated and accountable” efforts of the insurers partnering with health delivery entrepreneurs. Only the patients, patient-oriented health care professionals, and the patient-oriented hospitals will be losers.

Whatever you need – preventive services, continuing care for your chronic condition, or timely management of an acute problem – wouldn’t it be nice if you always had available your own personal physician’s team to meet your needs? With our fragmented, dysfunctional system
of financing health care, it is unlikely that in the future this will be more than a dream for the majority of us.

If we had our own Medicare-for-all monopsony (single purchaser of health care) it could become a reality for all of us. We would simply insist that a primary care system coordinating a full complement of specialized services is all that we’re going to pay for. The insurers and health profession entrepreneurs can take a hike.